Provider Demographics
NPI:1295981579
Name:MUELLER, BRENT S (PT)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:S
Last Name:MUELLER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15825 SE NEHALEM ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-5350
Mailing Address - Country:US
Mailing Address - Phone:971-322-9096
Mailing Address - Fax:
Practice Address - Street 1:1005 N EVERGREEN RD STE 10
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-1485
Practice Address - Country:US
Practice Address - Phone:509-926-5367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-18
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5645174400000X
WA602931272251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP01153281OtherRR MEDICARE
WA1295981579Medicaid
ORP01153281OtherRR MEDICARE