Provider Demographics
NPI:1649565722
Name:DEFORREST, BRYAN T (MA)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:T
Last Name:DEFORREST
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 S ORCAS ST STE 219
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98108-2652
Mailing Address - Country:US
Mailing Address - Phone:206-816-0960
Mailing Address - Fax:855-272-1649
Practice Address - Street 1:650 S ORCAS ST STE 219
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98108-2652
Practice Address - Country:US
Practice Address - Phone:206-816-0960
Practice Address - Fax:855-272-1649
Is Sole Proprietor?:No
Enumeration Date:2011-06-16
Last Update Date:2017-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60075925225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist