Provider Demographics
NPI:1528405909
Name:LOUCKS, BRENDA JO (LMP)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:JO
Last Name:LOUCKS
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 1:12209 NE 148TH CT
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-4511
Mailing Address - Country:US
Mailing Address - Phone:509-301-8582
Mailing Address - Fax:
Practice Address - Street 1:20833 67TH AVE W
Practice Address - Street 2:SUITE 301
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-7365
Practice Address - Country:US
Practice Address - Phone:425-760-8140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-26
Last Update Date:2013-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60314677225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist