Provider Demographics
NPI:1710387980
Name:GROESBECK, BRANDON (LMP)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:GROESBECK
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6501 196TH ST SW STE C
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-5980
Mailing Address - Country:US
Mailing Address - Phone:425-775-2288
Mailing Address - Fax:425-778-5476
Practice Address - Street 1:6501 196TH ST SW STE C
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-5980
Practice Address - Country:US
Practice Address - Phone:425-775-2288
Practice Address - Fax:425-778-5476
Is Sole Proprietor?:No
Enumeration Date:2014-08-25
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60313574225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist