Provider Demographics
NPI:1619391901
Name:BREIDEL, BROOKE ALEXIS (LMP)
Entity Type:Individual
Prefix:MS
First Name:BROOKE
Middle Name:ALEXIS
Last Name:BREIDEL
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:ALEXIS
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMP
Mailing Address - Street 1:4220 A ST. STE. 103
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98002
Mailing Address - Country:US
Mailing Address - Phone:253-833-4800
Mailing Address - Fax:
Practice Address - Street 1:4220 A ST. STE. 103
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002
Practice Address - Country:US
Practice Address - Phone:253-833-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-07
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60290342225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist