Provider Demographics
NPI:1063907350
Name:CHERRY, BRENNA ROSE
Entity type:Individual
Prefix:
First Name:BRENNA
Middle Name:ROSE
Last Name:CHERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12025 131ST LN NE APT E200
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-8074
Mailing Address - Country:US
Mailing Address - Phone:509-832-2129
Mailing Address - Fax:
Practice Address - Street 1:13010 NE 20TH ST STE 300
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98005-2054
Practice Address - Country:US
Practice Address - Phone:425-644-6328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-28
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician