Provider Demographics
NPI:1164813929
Name:SULLIVAN, BRENDA JEAN
Entity Type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:JEAN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8915 SW CENTER ST
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-6307
Mailing Address - Country:US
Mailing Address - Phone:503-726-3690
Mailing Address - Fax:
Practice Address - Street 1:720 SE WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4230
Practice Address - Country:US
Practice Address - Phone:503-648-0753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-13
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR175T00000X, 175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist