Provider Demographics
NPI:1437748944
Name:BRANUM, LEAH
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:BRANUM
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 1:15290 SW ROYALTY PKWY
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-4059
Mailing Address - Country:US
Mailing Address - Phone:503-607-6100
Mailing Address - Fax:
Practice Address - Street 1:15700 SW GREYSTONE CT
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-6011
Practice Address - Country:US
Practice Address - Phone:971-262-9150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-11
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORABA-IN-10211324106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORHM101O9AMedicaid