Provider Demographics
NPI:1396838009
Name:BREWER, ROBERT RAY (PT, MOMT)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:RAY
Last Name:BREWER
Suffix:
Gender:M
Credentials:PT, MOMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 909
Mailing Address - Street 2:
Mailing Address - City:CHEWELAH
Mailing Address - State:WA
Mailing Address - Zip Code:99109
Mailing Address - Country:US
Mailing Address - Phone:509-935-4988
Mailing Address - Fax:509-935-4985
Practice Address - Street 1:N. 119 3RD ST. E.
Practice Address - Street 2:
Practice Address - City:CHEWELAH
Practice Address - State:WA
Practice Address - Zip Code:99109
Practice Address - Country:US
Practice Address - Phone:509-935-4988
Practice Address - Fax:509-935-4985
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00003967225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7091564Medicaid
WA0123911OtherLABOR AND INDUSTRIES
WAS865856Medicare UPIN
WA7091564Medicaid