Provider Demographics
NPI:1659621076
Name:FREE, BRANDY M (LMP)
Entity Type:Individual
Prefix:MRS
First Name:BRANDY
Middle Name:M
Last Name:FREE
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 1:200 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:LA CENTER
Mailing Address - State:WA
Mailing Address - Zip Code:98629-9521
Mailing Address - Country:US
Mailing Address - Phone:360-608-3126
Mailing Address - Fax:
Practice Address - Street 1:1101 BROADWAY ST
Practice Address - Street 2:ST# 216
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98660-3268
Practice Address - Country:US
Practice Address - Phone:360-608-3126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-13
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 00022968225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist