Provider Demographics
NPI:1629062518
Name:HEROLD, BRENDA CAROL (PMHNP)
Entity Type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:CAROL
Last Name:HEROLD
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 14189
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97293-0189
Mailing Address - Country:US
Mailing Address - Phone:503-320-5001
Mailing Address - Fax:503-234-1952
Practice Address - Street 1:2905 SE MADISON ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-4154
Practice Address - Country:US
Practice Address - Phone:503-320-5001
Practice Address - Fax:503-234-1952
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR000035838N6363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORS63206Medicare UPIN