Provider Demographics
NPI:1578949012
Name:BRESOLIN, BRAD
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:
Last Name:BRESOLIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 1ST AVE NW
Mailing Address - Street 2:
Mailing Address - City:EPHRATA
Mailing Address - State:WA
Mailing Address - Zip Code:98823-1602
Mailing Address - Country:US
Mailing Address - Phone:509-925-7867
Mailing Address - Fax:509-925-7871
Practice Address - Street 1:120 1ST AVE NW
Practice Address - Street 2:
Practice Address - City:EPHRATA
Practice Address - State:WA
Practice Address - Zip Code:98823-1602
Practice Address - Country:US
Practice Address - Phone:509-925-7867
Practice Address - Fax:509-925-7871
Is Sole Proprietor?:No
Enumeration Date:2015-08-06
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00000105101YA0400X
WALH00006881101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health