MEDICARE: MS. BRENDA CAROL HEROLD PMHNP

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	000035838N6	OR

General Provider Information

NPI Number	:	1629062518
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. BRENDA CAROL HEROLD PMHNP

Provider Business Mailing Address
First Line	:	PO BOX 14189
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97293-0189
Country	:	US
Telephone Number	:	503-320-5001
Fax Number	:	503-234-1952

Provider Business Practice Location Address
First Line	:	2905 SE MADISON ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97214-4154
Country	:	US
Telephone Number	:	503-320-5001
Fax Number	:	503-234-1952

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

Provider Enumeration Date	:	09/07/2005
Last Update Date	:	05/15/2012

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