Provider Demographics
NPI:1750668398
Name:BRENDA HEROLD, INC.
Entity Type:Organization
Organization Name:BRENDA HEROLD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:CAROL
Authorized Official - Last Name:HEROLD
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:503-320-5001
Mailing Address - Street 1:2905 SE MADISON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-4154
Mailing Address - Country:US
Mailing Address - Phone:503-320-5001
Mailing Address - Fax:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-10
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORS63206Medicare UPIN
OR104841Medicare PIN