Provider Demographics
NPI:1225133663
Name:WAHLBERG, BRENT WESLEY JR (RPT)
Entity Type:Individual
Prefix:MR
First Name:BRENT
Middle Name:WESLEY
Last Name:WAHLBERG
Suffix:JR
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 6TH ST STE 101
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-2006
Mailing Address - Country:US
Mailing Address - Phone:509-758-8510
Mailing Address - Fax:509-751-9149
Practice Address - Street 1:725 6TH ST STE 101
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-2006
Practice Address - Country:US
Practice Address - Phone:509-758-8510
Practice Address - Fax:509-751-9149
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00005041225100000X
IDPT396225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA131422OtherL AND I
WA7018757Medicaid
000010007644OtherBLUE SHIELD
000010007644OtherBLUE SHIELD