Provider Demographics
NPI:1306145644
Name:EDGE, BRIAN (LMP)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:EDGE
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:PO BOX 14423
Mailing Address - Street 2:
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98082-2423
Mailing Address - Country:US
Mailing Address - Phone:360-632-3710
Mailing Address - Fax:
Practice Address - Street 1:4525 164TH ST SW
Practice Address - Street 2:# BB103
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98087-8609
Practice Address - Country:US
Practice Address - Phone:360-632-3710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-25
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60211133225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist