Healthcare Provider Details

I. General information

NPI: 1225961527
Provider Name (Legal Business Name): BRANDI AUTUMN HANNON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2026
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

182 SW ACADEMY ST
DALLAS OR
97338-1922
US

IV. Provider business mailing address

3041 GEHLAR RD NW APT 3043
SALEM OR
97304-4291
US

V. Phone/Fax

Practice location:
  • Phone: 503-962-3928
  • Fax:
Mailing address:
  • Phone: 971-287-8504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: