Provider Demographics
NPI:1417321266
Name:CONWELL, BROOK CHERITH (LMP)
Entity Type:Individual
Prefix:
First Name:BROOK
Middle Name:CHERITH
Last Name:CONWELL
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:PO BOX 256
Mailing Address - Street 2:
Mailing Address - City:NEAH BAY
Mailing Address - State:WA
Mailing Address - Zip Code:98357-0256
Mailing Address - Country:US
Mailing Address - Phone:360-640-5729
Mailing Address - Fax:
Practice Address - Street 1:1081 BAYVIEW AVE # 2
Practice Address - Street 2:
Practice Address - City:NEAH BAY
Practice Address - State:WA
Practice Address - Zip Code:98357-0109
Practice Address - Country:US
Practice Address - Phone:360-640-5729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-17
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60533403174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist