Healthcare Provider Details

I. General information

NPI: 1649565722
Provider Name (Legal Business Name): BRYAN T DEFORREST M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2011
Last Update Date: 10/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 S ORCAS ST STE 219
SEATTLE WA
98108-2652
US

IV. Provider business mailing address

650 S ORCAS ST STE 219
SEATTLE WA
98108-2652
US

V. Phone/Fax

Practice location:
  • Phone: 206-816-0960
  • Fax: 855-272-1649
Mailing address:
  • Phone: 206-816-0960
  • Fax: 855-272-1649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60075925
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: