Healthcare Provider Details

I. General information

NPI: 1275447534
Provider Name (Legal Business Name): ELLY BRAND
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

392 W MAIN AVE UNIT 102
SISTERS OR
97759-5009
US

IV. Provider business mailing address

375 W WASHINGTON AVE
SISTERS OR
97759-1338
US

V. Phone/Fax

Practice location:
  • Phone: 541-640-9310
  • Fax: 360-326-1978
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number26-QMHA-R-9041
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: