Provider Demographics
NPI:1841677234
Name:WILLARD, BREANNE NICHOLE (BA)
Entity type:Individual
Prefix:
First Name:BREANNE
Middle Name:NICHOLE
Last Name:WILLARD
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:BREANNE
Other - Middle Name:NICHOLE
Other - Last Name:MAUNDERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA
Mailing Address - Street 1:1201 S PROCTOR ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-2047
Mailing Address - Country:US
Mailing Address - Phone:253-396-5246
Mailing Address - Fax:
Practice Address - Street 1:610 YAKIMA AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4851
Practice Address - Country:US
Practice Address - Phone:253-396-5246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-05
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA10OtherCOMPREHENSIVE LIFE RESOURCES