Provider Demographics
NPI:1851620405
Name:PENDERGAST, BRIAN J (MA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
Last Name:PENDERGAST
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 1:1200 WESTLAKE AVE N
Mailing Address - Street 2:#901
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98109-3543
Mailing Address - Country:US
Mailing Address - Phone:253-797-9315
Mailing Address - Fax:
Practice Address - Street 1:1200 WESTLAKE AVE N
Practice Address - Street 2:#901
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98109-3543
Practice Address - Country:US
Practice Address - Phone:253-797-9315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-10
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH 60310936101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health