MEDICARE: BRENDA HEROLD, INC.

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

General Provider Information

NPI Number	:	1750668398
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRENDA HEROLD, INC.

Provider Business Mailing 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	:

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	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MS. BRENDA CAROL HEROLD
Credential	:	PMHNP
Telephone Number	:	503-320-5001

Provider Enumeration Date	:	11/10/2011
Last Update Date	:	11/10/2011

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