Provider Demographics
NPI:1841451424
Name:BINGHAM, BRENT G (LMT)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:G
Last Name:BINGHAM
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5525 N 19TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-3004
Mailing Address - Country:US
Mailing Address - Phone:928-961-4837
Mailing Address - Fax:
Practice Address - Street 1:5525 N 19TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-3004
Practice Address - Country:US
Practice Address - Phone:928-961-4837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-17
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT00834225700000X
UT6735789-4701225700000X
WAMA00025011225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist