Healthcare Provider Details

I. General information

NPI: 1073238432
Provider Name (Legal Business Name): BROOKE M TERRY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2022
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5441 S MACADAM AVE STE 5395
PORTLAND OR
97239-3822
US

IV. Provider business mailing address

PO BOX 5530
BOSSIER CITY LA
71171-5530
US

V. Phone/Fax

Practice location:
  • Phone: 323-393-3714
  • Fax:
Mailing address:
  • Phone: 601-383-1985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberR7934
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: