Provider Demographics
NPI:1841996683
Name:BRYDEN, LISA C
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:C
Last Name:BRYDEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:C
Other - Last Name:BOBB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:204 CUSTER WAY SW STE 103
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98501-3330
Mailing Address - Country:US
Mailing Address - Phone:360-451-6497
Mailing Address - Fax:
Practice Address - Street 1:204 CUSTER WAY SW STE 103
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98501-3330
Practice Address - Country:US
Practice Address - Phone:360-451-6497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-02
Last Update Date:2024-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW61485889104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WASC-61283236OtherLSWAIC