Provider Demographics
NPI:1871681130
Name:BLACK, BRENDA LYNN (AT,C)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:LYNN
Last Name:BLACK
Suffix:
Gender:F
Credentials:AT,C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24205 54TH AVE W
Mailing Address - Street 2:
Mailing Address - City:MOUNTLAKE TERRACE
Mailing Address - State:WA
Mailing Address - Zip Code:98043-5515
Mailing Address - Country:US
Mailing Address - Phone:425-697-2453
Mailing Address - Fax:425-385-7002
Practice Address - Street 1:1508 136TH ST SE
Practice Address - Street 2:
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-5310
Practice Address - Country:US
Practice Address - Phone:425-385-7038
Practice Address - Fax:425-385-7002
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer