Provider Demographics
NPI:1609085687
Name:BRUBAKER, DUSTIN M (LMP, CMT)
Entity Type:Individual
Prefix:MR
First Name:DUSTIN
Middle Name:M
Last Name:BRUBAKER
Suffix:
Gender:M
Credentials:LMP, CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 SE 124TH AVE
Mailing Address - Street 2:STE. 18
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-6015
Mailing Address - Country:US
Mailing Address - Phone:360-713-7437
Mailing Address - Fax:
Practice Address - Street 1:108 SE 124TH AVE
Practice Address - Street 2:STE. 18
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-6015
Practice Address - Country:US
Practice Address - Phone:360-713-7437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00019889225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist