Provider Demographics
NPI:1225219132
Name:NIEDERT, BRENDA
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:NIEDERT
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 1:12042 SE SUNNYSIDE RD # 271
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-8382
Mailing Address - Country:US
Mailing Address - Phone:503-902-5040
Mailing Address - Fax:
Practice Address - Street 1:12042 SE SUNNYSIDE RD # 271
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-8382
Practice Address - Country:US
Practice Address - Phone:503-902-5040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-19
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR6854101YM0800X
CAIMF60661106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist