Healthcare Provider Details

I. General information

NPI: 1548385727
Provider Name (Legal Business Name): BRENDA SIMONE HASKETT LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

177 HOWERTON WAY
ILWACO WA
98631
US

IV. Provider business mailing address

40 AUBURN ST
ASTORIA OR
97103-5606
US

V. Phone/Fax

Practice location:
  • Phone: 360-642-4080
  • Fax:
Mailing address:
  • Phone: 503-440-5051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00018279
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: