Healthcare Provider Details

I. General information

NPI: 1053483024
Provider Name (Legal Business Name): YULIA BROCKDORF RD LD CD LPC BCADM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 11/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

428 SW OAK ST
HILLSBORO OR
97123-3936
US

IV. Provider business mailing address

428 SW OAK ST
HILLSBORO OR
97123-3936
US

V. Phone/Fax

Practice location:
  • Phone: 503-577-5845
  • Fax: 503-844-6545
Mailing address:
  • Phone: 503-577-5845
  • Fax: 503-844-6545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC4518
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number594
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: