Provider Demographics
NPI:1205981594
Name:BAKKE, BRENDA K (MED, PT)
Entity type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:K
Last Name:BAKKE
Suffix:
Gender:F
Credentials:MED, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23606 5TH AVE W
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98021-8526
Mailing Address - Country:US
Mailing Address - Phone:425-485-1554
Mailing Address - Fax:425-485-1554
Practice Address - Street 1:23606 5TH AVE W
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98021-8526
Practice Address - Country:US
Practice Address - Phone:425-485-1554
Practice Address - Fax:425-485-1554
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00004070225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7100126Medicaid