Healthcare Provider Details

I. General information

NPI: 1164990016
Provider Name (Legal Business Name): BRENTON LOVELETTE MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2018
Last Update Date: 02/04/2022
Certification Date: 02/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 S PLUM ST
SEATTLE WA
98144-4539
US

IV. Provider business mailing address

222 WALL ST STE 100
SEATTLE WA
98121-1431
US

V. Phone/Fax

Practice location:
  • Phone: 206-441-3043
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCG60146031
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLW61169502
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: