Provider Demographics
NPI:1558554360
Name:EISENBRAUN, TRICIA LEA (RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:TRICIA
Middle Name:LEA
Last Name:EISENBRAUN
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:TRICIA
Other - Middle Name:LEA
Other - Last Name:SLADE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD LD
Mailing Address - Street 1:541 NE 20TH AVE STE 225
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2895
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2825
Practice Address - Street 1:1111 NE 99TH AVE STE 301
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-9442
Practice Address - Country:US
Practice Address - Phone:503-963-2707
Practice Address - Fax:503-963-2802
Is Sole Proprietor?:No
Enumeration Date:2007-08-24
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00002009133V00000X
ORLD-D-10174920133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500795097Medicaid
WA2189112Medicaid