Provider Demographics
NPI:1649783622
Name:WRZESINSKI, BREA ANN (MA60771416)
Entity type:Individual
Prefix:
First Name:BREA
Middle Name:ANN
Last Name:WRZESINSKI
Suffix:
Gender:F
Credentials:MA60771416
Other - Prefix:
Other - First Name:BREA
Other - Middle Name:ANN
Other - Last Name:WRZESINSKI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:PO BOX 3478
Mailing Address - Street 2:3609 168TH ST NE
Mailing Address - City:ARLINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98223-3478
Mailing Address - Country:US
Mailing Address - Phone:360-854-8547
Mailing Address - Fax:
Practice Address - Street 1:9623 32ND ST SE
Practice Address - Street 2:
Practice Address - City:LAKE STEVENS
Practice Address - State:WA
Practice Address - Zip Code:98258-5779
Practice Address - Country:US
Practice Address - Phone:360-854-8547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-13
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60771416225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA60771416OtherMASSAGE THERAPY LICENSE