Healthcare Provider Details

I. General information

NPI: 1053644955
Provider Name (Legal Business Name): BRYCE LEO VRADENBURG MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2009
Last Update Date: 09/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4526 FEDERAL AVE BUILDING #1
EVERETT WA
98203-2132
US

IV. Provider business mailing address

PO BOX 3810
EVERETT WA
98213-8810
US

V. Phone/Fax

Practice location:
  • Phone: 425-349-8300
  • Fax: 425-349-3804
Mailing address:
  • Phone: 425-349-8300
  • Fax: 425-349-8304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: