Healthcare Provider Details

I. General information

NPI: 1831646702
Provider Name (Legal Business Name): BRYN NICOLE WEST-WALLACE MOT, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2016
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 SW 7TH ST
RENTON WA
98057-2307
US

IV. Provider business mailing address

2465 S 121ST ST
BURIEN WA
98168-2422
US

V. Phone/Fax

Practice location:
  • Phone: 425-204-2300
  • Fax:
Mailing address:
  • Phone: 425-204-2238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT 60647916
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: