Provider Demographics
NPI:1104221571
Name:A MOMENT FOR YOU PLLC
Entity type:Organization
Organization Name:A MOMENT FOR YOU PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OWNER/LMP
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:DEFORREST
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:206-601-8334
Mailing Address - Street 1:650 S ORCAS ST
Mailing Address - Street 2:SUITE 219
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98108
Mailing Address - Country:US
Mailing Address - Phone:206-456-4463
Mailing Address - Fax:855-272-1649
Practice Address - Street 1:650 S ORCAS ST STE 219
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98108-2652
Practice Address - Country:US
Practice Address - Phone:206-456-4463
Practice Address - Fax:855-272-1649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-28
Last Update Date:2017-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60306672225700000X
WAMA60075925225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty