Basic Information
| Provider Information | |||||||||
| NPI: | 1174944334 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANSFIELD | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1119 NW POPPY CT | ||||||||
| Address2: | |||||||||
| City: | SILVERDALE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983837994 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8319179842 | ||||||||
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| Practice Location | |||||||||
| Address1: | 732 LEBO BLVD | ||||||||
| Address2: | |||||||||
| City: | BREMERTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983103325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604798477 | ||||||||
| FaxNumber: | 9519737216 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2013 | ||||||||
| LastUpdateDate: | 03/22/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 40819 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 60940282 | 01 | WA | PT LICENSE | OTHER |