MEDICARE: BENJAMIN BROENEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	175T00000X	Peer Specialist	23-CRM-2237	OR

General Provider Information

NPI Number	:	1437831021
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BENJAMIN BROENEN

Provider Business Mailing Address
First Line	:	232 NW 6TH AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97209-3609
Country	:	US
Telephone Number	:	503-294-1681
Fax Number	:

Provider Business Practice Location Address
First Line	:	5019 NE 102ND AVE UNIT A
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97220-1199
Country	:	US
Telephone Number	:	971-383-1220
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/02/2023
Last Update Date	:	08/02/2023

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Directions to “ BENJAMIN BROENEN ” Practice Location

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