MEDICARE: MR. BRAD MITCHELL SECREST L.M.P.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	MA00016543	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MA00016543	OTHER	WA	STATE LICENSE

General Provider Information

NPI Number	:	1316922610
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRAD MITCHELL SECREST L.M.P.

Provider Business Mailing Address
First Line	:	8612 E ROWAN LN
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99217-9237
Country	:	US
Telephone Number	:	509-464-2273
Fax Number	:	509-242-1954

Provider Business Practice Location Address
First Line	:	9720 N NEVADA ST
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99218-3412
Country	:	US
Telephone Number	:	509-464-2273
Fax Number	:	509-242-1854

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/08/2005
Last Update Date	:	07/08/2007

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Directions to “ MR. BRAD MITCHELL SECREST L.M.P.” Practice Location

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