Healthcare Provider Details

I. General information

NPI: 1255121687
Provider Name (Legal Business Name): RYA FAYEQ BROSSARD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2025
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1234 COMMERCIAL ST SE
SALEM OR
97302-4204
US

IV. Provider business mailing address

222 SE 8TH AVE STE 212
HILLSBORO OR
97123-4218
US

V. Phone/Fax

Practice location:
  • Phone: 503-352-2400
  • Fax: 503-585-4949
Mailing address:
  • Phone: 503-352-2400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: