Provider Demographics
NPI:1326385337
Name:PEWITT, BRADEN WAYNE (LMP)
Entity Type:Individual
Prefix:
First Name:BRADEN
Middle Name:WAYNE
Last Name:PEWITT
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:718 S COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:99324-1519
Mailing Address - Country:US
Mailing Address - Phone:509-240-4913
Mailing Address - Fax:
Practice Address - Street 1:718 S COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:COLLEGE PLACE
Practice Address - State:WA
Practice Address - Zip Code:99324-1519
Practice Address - Country:US
Practice Address - Phone:509-240-4913
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-10
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60305071225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist