Provider Demographics
NPI:1154332864
Name:NISSLEY, BRENDA V (OT)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:V
Last Name:NISSLEY
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 9TH AVE
Mailing Address - Street 2:BOX 359750
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-2420
Mailing Address - Country:US
Mailing Address - Phone:206-744-9888
Mailing Address - Fax:206-744-9773
Practice Address - Street 1:325 9TH AVE
Practice Address - Street 2:BOX 359827
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-2420
Practice Address - Country:US
Practice Address - Phone:206-731-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT00002702225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA82744UOtherREGENCE BLUE SHIELD PIN