Healthcare Provider Details

I. General information

NPI: 1548497654
Provider Name (Legal Business Name): BRETT D NEILSON PT, DPT, OCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2009
Last Update Date: 11/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8009 S 180TH ST STE 112
KENT WA
98032-1042
US

IV. Provider business mailing address

26837 MAPLE VALLEY BLACK DIAMOND SERD 200
MAPLE VALLEY WA
98038-9917
US

V. Phone/Fax

Practice location:
  • Phone: 425-226-7827
  • Fax:
Mailing address:
  • Phone: 425-413-4427
  • Fax: 425-413-4402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT60095972
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: