Provider Demographics
NPI:1306194550
Name:WITHEROW, BRENDA JOANNE (LMP)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:JOANNE
Last Name:WITHEROW
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3011A 132ND ST SE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-6136
Mailing Address - Country:US
Mailing Address - Phone:425-337-1218
Mailing Address - Fax:
Practice Address - Street 1:547 DAYTON ST
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98020-3431
Practice Address - Country:US
Practice Address - Phone:425-771-5166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-20
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60227121225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist