Healthcare Provider Details

I. General information

NPI: 1750145876
Provider Name (Legal Business Name): ETHAN BRADY BRASSARD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2024
Last Update Date: 02/08/2024
Certification Date: 02/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8811 S TACOMA WAY STE 204&206
LAKEWOOD WA
98499-4595
US

IV. Provider business mailing address

615 N YAKIMA AVE
TACOMA WA
98403-2417
US

V. Phone/Fax

Practice location:
  • Phone: 425-217-1140
  • Fax:
Mailing address:
  • Phone: 253-442-4379
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: