Provider Demographics
NPI:1124664784
Name:SQUIBB, BRYANNA JO (HM60795744)
Entity type:Individual
Prefix:MISS
First Name:BRYANNA
Middle Name:JO
Last Name:SQUIBB
Suffix:
Gender:F
Credentials:HM60795744
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:83 SW 10TH ST
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-4704
Mailing Address - Country:US
Mailing Address - Phone:360-269-3856
Mailing Address - Fax:
Practice Address - Street 1:3510 STEELHAMMER DR
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-4551
Practice Address - Country:US
Practice Address - Phone:360-623-8020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-19
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health