Provider Demographics
NPI:1336437565
Name:BREZLER, CAROLYN MAE (LMP)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:MAE
Last Name:BREZLER
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:MAE
Other - Last Name:GORDY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMP
Mailing Address - Street 1:1040 MEGAN CT E
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-8423
Mailing Address - Country:US
Mailing Address - Phone:360-434-3431
Mailing Address - Fax:
Practice Address - Street 1:200 BETHEL AVE
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-5216
Practice Address - Country:US
Practice Address - Phone:360-876-4171
Practice Address - Fax:360-876-3495
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-21
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60204666174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist