Provider Demographics
NPI:1598359804
Name:DAMIANO, BRANDEE FANCHON (CRM)
Entity Type:Individual
Prefix:
First Name:BRANDEE
Middle Name:FANCHON
Last Name:DAMIANO
Suffix:
Gender:F
Credentials:CRM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 WASHINGTON ST APT A3
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-2257
Mailing Address - Country:US
Mailing Address - Phone:503-732-5128
Mailing Address - Fax:
Practice Address - Street 1:505 WASHINGTON ST APT A3
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-2257
Practice Address - Country:US
Practice Address - Phone:503-732-5128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-26
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21-CRM-341175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR21-CRM-341OtherCRM
ORTHW000104559Medicaid