Provider Demographics
NPI:1689349953
Name:BRIGHAM, RANDI MARIE (MA00013095)
Entity Type:Individual
Prefix:
First Name:RANDI
Middle Name:MARIE
Last Name:BRIGHAM
Suffix:
Gender:F
Credentials:MA00013095
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20571 ENGLISH RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-7571
Mailing Address - Country:US
Mailing Address - Phone:360-333-4439
Mailing Address - Fax:
Practice Address - Street 1:300 S 1ST ST STE 205
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-3895
Practice Address - Country:US
Practice Address - Phone:360-333-4439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00013095225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA00013095OtherMASSAGE THERAPY