Provider Demographics
NPI:1275809709
Name:CORSE, BRADY W (ATC/L)
Entity Type:Individual
Prefix:
First Name:BRADY
Middle Name:W
Last Name:CORSE
Suffix:
Gender:M
Credentials:ATC/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 NE MOTHER JOSEPH PLACE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664
Mailing Address - Country:US
Mailing Address - Phone:360-514-2048
Mailing Address - Fax:360-514-5033
Practice Address - Street 1:200 NE MOTHER JOSEPH PLACE
Practice Address - Street 2:SUITE 100
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664
Practice Address - Country:US
Practice Address - Phone:360-514-2048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-29
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA600688952255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer