Basic Information
Provider Information | |||||||||
NPI: | 1912247594 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BALL | ||||||||
FirstName: | BRANDAIS | ||||||||
MiddleName: | FAYE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5006 CENTER ST | ||||||||
Address2: | SUITE N | ||||||||
City: | TACOMA | ||||||||
State: | WA | ||||||||
PostalCode: | 984092314 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2534760449 | ||||||||
FaxNumber: | 2534760286 | ||||||||
Practice Location | |||||||||
Address1: | 5006 CENTER ST | ||||||||
Address2: | SUITE N | ||||||||
City: | TACOMA | ||||||||
State: | WA | ||||||||
PostalCode: | 984092314 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2534760449 | ||||||||
FaxNumber: | 2534760286 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/19/2013 | ||||||||
LastUpdateDate: | 02/19/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | MA 60282022 | WA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |   |
ID Information
ID | Type | State | Issuer | Description | MA 60282022 | 01 | WA | MASSAGE PRACTITIONER LICENSE | OTHER |