Healthcare Provider Details

I. General information

NPI: 1841996683
Provider Name (Legal Business Name): LISA C BRYDEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA C BOBB

II. Dates (important events)

Enumeration Date: 02/02/2023
Last Update Date: 12/01/2024
Certification Date: 12/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 CUSTER WAY SW STE 103
TUMWATER WA
98501-3330
US

IV. Provider business mailing address

204 CUSTER WAY SW STE 103
TUMWATER WA
98501-3330
US

V. Phone/Fax

Practice location:
  • Phone: 360-451-6497
  • Fax:
Mailing address:
  • Phone: 360-451-6497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLW61485889
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: