=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073806576
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIAN DESROCHES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2011
-----------------------------------------------------
Last Update Date | 11/29/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2719 E MADISON ST SUITE 300
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98112-4752
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-323-6114
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2719 E MADISON ST SUITE 300
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98112-4752
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-323-6114
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. BRIAN DESROCHES
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 206-323-6114
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number | 1459
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------