Healthcare Provider Details

I. General information

NPI: 1184786410
Provider Name (Legal Business Name): BRIAN J CHASE MOT OTRL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 10/05/2021
Certification Date: 10/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 DENNIS ST SW STE A
TUMWATER WA
98501-6523
US

IV. Provider business mailing address

100 DENNIS ST SW STE B
TUMWATER WA
98501-6523
US

V. Phone/Fax

Practice location:
  • Phone: 360-819-4335
  • Fax: 360-819-4339
Mailing address:
  • Phone: 360-338-0181
  • Fax: 360-338-0257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT00003562
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: