Healthcare Provider Details

I. General information

NPI: 1366545246
Provider Name (Legal Business Name): BRENNA AILIENE CHOLERTON PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 11/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9600 VETERANS DR SW GRECC-A-182
TACOMA WA
98493-0003
US

IV. Provider business mailing address

20 RAFT ISLAND DR NW
GIG HARBOR WA
98335-5918
US

V. Phone/Fax

Practice location:
  • Phone: 253-582-8440
  • Fax: 253-589-4073
Mailing address:
  • Phone: 253-582-8440
  • Fax: 253-589-4073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPY2589
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY2589
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: