Provider Demographics
NPI:1316922610
Name:SECREST, BRAD MITCHELL (LMP)
Entity type:Individual
Prefix:MR
First Name:BRAD
Middle Name:MITCHELL
Last Name:SECREST
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:8612 E ROWAN LN
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99217-9237
Mailing Address - Country:US
Mailing Address - Phone:509-464-2273
Mailing Address - Fax:509-242-1954
Practice Address - Street 1:9720 N NEVADA ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99218-3412
Practice Address - Country:US
Practice Address - Phone:509-464-2273
Practice Address - Fax:509-242-1854
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMA00016543225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA00016543OtherSTATE LICENSE