Provider Demographics
NPI:1073641064
Name:BROCKMAN, MIKE W (CADC II/QMHA-I)
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:W
Last Name:BROCKMAN
Suffix:
Gender:M
Credentials:CADC II/QMHA-I
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:W
Other - Last Name:BROCKMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CADC II/QMHA-I
Mailing Address - Street 1:1776 SW MADISON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1715
Mailing Address - Country:US
Mailing Address - Phone:971-386-2278
Mailing Address - Fax:503-224-4494
Practice Address - Street 1:1631 SW COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-6025
Practice Address - Country:US
Practice Address - Phone:503-231-2641
Practice Address - Fax:503-231-1654
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19-QMHA-I-01468101YM0800X
OR15-10-21101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500694604Medicaid
OR500777728Medicaid