Provider Demographics
NPI:1497893226
Name:RAY, BRENDA J (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:J
Last Name:RAY
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:18130 105TH ST SE
Mailing Address - Street 2:
Mailing Address - City:SNOHOMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98290-2148
Mailing Address - Country:US
Mailing Address - Phone:360-794-1061
Mailing Address - Fax:360-805-9491
Practice Address - Street 1:1129 W MAIN ST STE 194
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-2034
Practice Address - Country:US
Practice Address - Phone:360-794-1061
Practice Address - Fax:360-794-9491
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00003884235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2146017Medicaid