=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124482435
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHRIS BRUBAKER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2016
-----------------------------------------------------
Last Update Date | 04/12/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2825 EASTLAKE AVE E SUITE 120
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98102-3062
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-486-4993
-----------------------------------------------------
Fax | 206-535-6838
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2825 EASTLAKE AVE E SUITE 120
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98102-3062
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-486-4993
-----------------------------------------------------
Fax | 206-535-6838
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. CHRISTOPHER J BRUBAKER
-----------------------------------------------------
Credential | M.D., PH.D.
-----------------------------------------------------
Telephone | 206-486-4993
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | 60301735
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------