Provider Demographics
NPI:1497806277
Name:BRATVOLD, KATHRYN JO (LMP)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:JO
Last Name:BRATVOLD
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 7848
Mailing Address - Street 2:
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391-0981
Mailing Address - Country:US
Mailing Address - Phone:253-863-0855
Mailing Address - Fax:253-826-0511
Practice Address - Street 1:603 HUNT AVE
Practice Address - Street 2:
Practice Address - City:SUMNER
Practice Address - State:WA
Practice Address - Zip Code:98390-1117
Practice Address - Country:US
Practice Address - Phone:253-863-0855
Practice Address - Fax:253-826-0511
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00013510225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA135620OtherL&I PROVIDER NUMBER
WA6630BROtherREGENCE PROVIDER NUMBER