Provider Demographics
NPI:1467793497
Name:BRESHEM, KENARI (LMP)
Entity Type:Individual
Prefix:
First Name:KENARI
Middle Name:
Last Name:BRESHEM
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:OLIVE
Other - Middle Name:K
Other - Last Name:BRESHEM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMP
Mailing Address - Street 1:PO BOX 500
Mailing Address - Street 2:
Mailing Address - City:OMAK
Mailing Address - State:WA
Mailing Address - Zip Code:98841-0500
Mailing Address - Country:US
Mailing Address - Phone:360-915-2062
Mailing Address - Fax:
Practice Address - Street 1:25 ASH ST
Practice Address - Street 2:
Practice Address - City:OMAK
Practice Address - State:WA
Practice Address - Zip Code:98841
Practice Address - Country:US
Practice Address - Phone:360-915-2062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-15
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60305883225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist