Healthcare Provider Details

I. General information

NPI: 1871155580
Provider Name (Legal Business Name): BROOKE RIVER ELIZABETH WYLIE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2019
Last Update Date: 07/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 AIRPORT WAY S
SEATTLE WA
98134-1618
US

IV. Provider business mailing address

12501 4TH AVE W APT 9104
EVERETT WA
98204-6419
US

V. Phone/Fax

Practice location:
  • Phone: 206-223-3644
  • Fax:
Mailing address:
  • Phone: 425-686-5013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: