Healthcare Provider Details

I. General information

NPI: 1881069144
Provider Name (Legal Business Name): BRENDA ROYAL MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2015
Last Update Date: 12/16/2024
Certification Date: 12/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 W MADRONE ST
ROSEBURG OR
97470-3090
US

IV. Provider business mailing address

PO BOX 1121
ROSEBURG OR
97470-0254
US

V. Phone/Fax

Practice location:
  • Phone: 541-440-3532
  • Fax: 541-440-3554
Mailing address:
  • Phone: 541-440-3532
  • Fax: 541-440-3554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC6046
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: