Provider Demographics
NPI:1710587969
Name:PAGE, BRENTON BROOKS JR (LMHCA)
Entity Type:Individual
Prefix:
First Name:BRENTON
Middle Name:BROOKS
Last Name:PAGE
Suffix:JR
Gender:M
Credentials:LMHCA
Other - Prefix:
Other - First Name:BROOKS
Other - Middle Name:
Other - Last Name:PAGE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMHCA
Mailing Address - Street 1:3036 60TH AVE SW APT 6
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98116-5801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:819 N 49TH ST STE 303
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-6577
Practice Address - Country:US
Practice Address - Phone:206-588-6585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC61056790101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health