Provider Demographics
NPI:1619433844
Name:BRAUN, BLUE MAKAYLA-CHRISTINA (BA)
Entity Type:Individual
Prefix:MS
First Name:BLUE
Middle Name:MAKAYLA-CHRISTINA
Last Name:BRAUN
Suffix:
Gender:F
Credentials:BA
Other - Prefix:MS
Other - First Name:MAKAYLA
Other - Middle Name:CHRISTINA
Other - Last Name:BRAUN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8915 SW CENTER ST
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-6307
Mailing Address - Country:US
Mailing Address - Phone:503-726-3690
Mailing Address - Fax:
Practice Address - Street 1:233 SW WALLULA AVE
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97080-6858
Practice Address - Country:US
Practice Address - Phone:503-924-1220
Practice Address - Fax:503-924-1221
Is Sole Proprietor?:No
Enumeration Date:2019-02-12
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3703577101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health