Provider Demographics
NPI:1023642659
Name:BRIGHAM, CAROL MAE (SUDP)
Entity type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:MAE
Last Name:BRIGHAM
Suffix:
Gender:F
Credentials:SUDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:614 DIVISION ST # MS -19
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-4614
Mailing Address - Country:US
Mailing Address - Phone:360-337-4625
Mailing Address - Fax:360-337-4704
Practice Address - Street 1:614 DIVISION ST # MS -19
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-4614
Practice Address - Country:US
Practice Address - Phone:360-337-4625
Practice Address - Fax:360-337-4704
Is Sole Proprietor?:No
Enumeration Date:2020-02-21
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00001469101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA090515Medicaid