Provider Demographics
NPI:1275645061
Name:BROOKE, MICHAEL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:BROOKE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 SE MORRISON ST
Mailing Address - Street 2:STE 310
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-2327
Mailing Address - Country:US
Mailing Address - Phone:503-235-8696
Mailing Address - Fax:503-235-0255
Practice Address - Street 1:516 SE MORRISON ST
Practice Address - Street 2:STE 310
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-2327
Practice Address - Country:US
Practice Address - Phone:503-481-0020
Practice Address - Fax:503-235-0255
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00003704103TC0700X
OR1830103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical