Provider Demographics
NPI:1134204977
Name:BRADY, SHELLEY MARIE (LMP)
Entity type:Individual
Prefix:MS
First Name:SHELLEY
Middle Name:MARIE
Last Name:BRADY
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 S STEVENS ST STE 101
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-1200
Mailing Address - Country:US
Mailing Address - Phone:509-939-4648
Mailing Address - Fax:321-260-5100
Practice Address - Street 1:169 S STEVENS ST STE 101
Practice Address - Street 2:SUITE 101
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-1200
Practice Address - Country:US
Practice Address - Phone:509-939-4648
Practice Address - Fax:321-260-6634
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA5184174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
200066455OtherFEDERAL TAX ID #
WA0074607OtherL&I PROVIDER #