Healthcare Provider Details

I. General information

NPI: 1679861504
Provider Name (Legal Business Name): BRENDA HELEN SAMPLES OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2011
Last Update Date: 07/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1355 W MAIN ST
MONROE WA
98272-2022
US

IV. Provider business mailing address

970 5TH AVE NW SUITE 7
ISSAQUAH WA
98027-2469
US

V. Phone/Fax

Practice location:
  • Phone: 360-794-4011
  • Fax:
Mailing address:
  • Phone: 253-230-5641
  • Fax: 253-912-4774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberOT 00000193
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: