Healthcare Provider Details

I. General information

NPI: 1356523112
Provider Name (Legal Business Name): KINDI ELAINE BRUMBAUGH MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2007
Last Update Date: 12/03/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 NE BURNSIDE RD BUILDING B, SUITE 401
GRESHAM OR
97030-6722
US

IV. Provider business mailing address

1217 NE BURNSIDE RD BUILDING B, SUITE 401
GRESHAM OR
97030-6722
US

V. Phone/Fax

Practice location:
  • Phone: 503-666-8832
  • Fax: 503-669-8641
Mailing address:
  • Phone: 503-666-8832
  • Fax: 503-669-8641

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier164936
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: