Provider Demographics
NPI:1104475102
Name:OWEN, BREANNA LEE
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:LEE
Last Name:OWEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BREANNA
Other - Middle Name:LEE
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1901 CORNWALL AVE # 1176
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-3659
Mailing Address - Country:US
Mailing Address - Phone:360-209-7333
Mailing Address - Fax:
Practice Address - Street 1:1901 CORNWALL AVE # 1176
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-3659
Practice Address - Country:US
Practice Address - Phone:360-209-7333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-11
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61079323101YM0800X
390200000X
WA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program