Provider Demographics
NPI:1831187814
Name:BRENNECKE, SHARI J (MPT)
Entity type:Individual
Prefix:
First Name:SHARI
Middle Name:J
Last Name:BRENNECKE
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12910 TOTEM LAKE BLVD NE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-2954
Mailing Address - Country:US
Mailing Address - Phone:425-814-5080
Mailing Address - Fax:
Practice Address - Street 1:12910 TOTEM LAKE BLVD NE
Practice Address - Street 2:SUITE 101
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-2954
Practice Address - Country:US
Practice Address - Phone:425-814-5080
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00008078225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8379992Medicaid
WAP63684Medicare UPIN
WA8379992Medicaid