Provider Demographics
NPI:1750145876
Name:BRASSARD, ETHAN BRADY
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:BRADY
Last Name:BRASSARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 N YAKIMA AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98403-2417
Mailing Address - Country:US
Mailing Address - Phone:253-442-4379
Mailing Address - Fax:
Practice Address - Street 1:8811 S TACOMA WAY STE 204&206
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-4595
Practice Address - Country:US
Practice Address - Phone:425-217-1140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-08
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician