Provider Demographics
NPI:1326213596
Name:MONTOYA, BREANNA J (MA)
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:J
Last Name:MONTOYA
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:BREANNA
Other - Middle Name:J
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:2111 NW BLACK PINES PL
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-1678
Mailing Address - Country:US
Mailing Address - Phone:541-788-9642
Mailing Address - Fax:
Practice Address - Street 1:384 SW UPPER TERRACE DR STE 202
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-3432
Practice Address - Country:US
Practice Address - Phone:541-788-9642
Practice Address - Fax:651-647-1413
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-28
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
ORT1340106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500661132Medicaid
OR500661132Medicaid