Provider Demographics
NPI:1548679012
Name:VICKERY, BRANDEY (LMP)
Entity type:Individual
Prefix:
First Name:BRANDEY
Middle Name:
Last Name:VICKERY
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28640 27TH PL S
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-3307
Mailing Address - Country:US
Mailing Address - Phone:509-885-6892
Mailing Address - Fax:
Practice Address - Street 1:33650 6TH AVE S
Practice Address - Street 2:SUITE 100
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-3307
Practice Address - Country:US
Practice Address - Phone:253-942-3303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-08
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60484302225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist