Provider Demographics
NPI:1881275154
Name:WALLENTINE, BRANDI ANN
Entity type:Individual
Prefix:
First Name:BRANDI
Middle Name:ANN
Last Name:WALLENTINE
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:PO BOX 557
Mailing Address - Street 2:
Mailing Address - City:SEABECK
Mailing Address - State:WA
Mailing Address - Zip Code:98380-0557
Mailing Address - Country:US
Mailing Address - Phone:425-890-3061
Mailing Address - Fax:
Practice Address - Street 1:7282 STINSON AVE STE B
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-4930
Practice Address - Country:US
Practice Address - Phone:253-858-5846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61145146101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health