Provider Demographics
NPI:1376536243
Name:THACKER, BRIAN A (DPT, OCS, SCS, COMT)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:A
Last Name:THACKER
Suffix:
Gender:M
Credentials:DPT, OCS, SCS, COMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 24283
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-0283
Mailing Address - Country:US
Mailing Address - Phone:253-581-5200
Mailing Address - Fax:253-581-5203
Practice Address - Street 1:17520 MERIDIAN E
Practice Address - Street 2:STE F
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98375-6265
Practice Address - Country:US
Practice Address - Phone:253-864-7595
Practice Address - Fax:253-864-0457
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00007968225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA306726OtherL&I PROVIDER ID
WA7092208Medicaid
WA306726OtherL&I PROVIDER ID