Provider Demographics
NPI:1124367628
Name:WORDEN, BRIAN DAVID (LMP)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:DAVID
Last Name:WORDEN
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17144 WEAVER LN SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:WA
Mailing Address - Zip Code:98579-9685
Mailing Address - Country:US
Mailing Address - Phone:206-423-1592
Mailing Address - Fax:360-539-7336
Practice Address - Street 1:2401 BRISTOL CT SW
Practice Address - Street 2:SUITE A - 102
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-6003
Practice Address - Country:US
Practice Address - Phone:360-350-0539
Practice Address - Fax:360-539-7336
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-05
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60320485225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist