Provider Demographics
NPI:1871166504
Name:STACY-RODRIGUEZ, BREE ANN
Entity type:Individual
Prefix:
First Name:BREE
Middle Name:ANN
Last Name:STACY-RODRIGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 LIMITED LN NW STE 100
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-2704
Mailing Address - Country:US
Mailing Address - Phone:360-292-7245
Mailing Address - Fax:
Practice Address - Street 1:1702 S 72ND ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98408-1238
Practice Address - Country:US
Practice Address - Phone:253-474-0677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-20
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225700000X
WAMA6113774225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist