Provider Demographics
NPI:1366708646
Name:MILLS, BRENDA Q (LMP)
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:Q
Last Name:MILLS
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 1:1104 MAIN ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98660-2999
Mailing Address - Country:US
Mailing Address - Phone:360-931-3867
Mailing Address - Fax:
Practice Address - Street 1:1104 MAIN ST
Practice Address - Street 2:SUITE #105
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98660
Practice Address - Country:US
Practice Address - Phone:360-931-3867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-11
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60250697225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist