Provider Demographics
NPI:1477833390
Name:BROOKS, SUMNER L (MPH, RD, CSSD)
Entity Type:Individual
Prefix:
First Name:SUMNER
Middle Name:L
Last Name:BROOKS
Suffix:
Gender:F
Credentials:MPH, RD, CSSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:847 NE 19TH AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2684
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2825
Practice Address - Street 1:1111 NE 99TH AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-9428
Practice Address - Country:US
Practice Address - Phone:503-963-2707
Practice Address - Fax:503-963-2802
Is Sole Proprietor?:No
Enumeration Date:2011-08-23
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA987508133V00000X
ORLD-D-10169435133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2065312Medicaid
OR500714219Medicaid
OR189538Medicare PIN