Provider Demographics
NPI:1477198315
Name:BROWN, EMI SUMIDA
Entity Type:Individual
Prefix:
First Name:EMI
Middle Name:SUMIDA
Last Name:BROWN
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 1:993 NW CIRCLE BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-1408
Mailing Address - Country:US
Mailing Address - Phone:541-829-3400
Mailing Address - Fax:
Practice Address - Street 1:993 NW CIRCLE BLVD STE A
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-1408
Practice Address - Country:US
Practice Address - Phone:541-829-3400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-14
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2387103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty