Provider Demographics
NPI:1801227384
Name:BRUTSAERT, MARIJKE L (LCSW)
Entity Type:Individual
Prefix:
First Name:MARIJKE
Middle Name:L
Last Name:BRUTSAERT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:BRUTSAERT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:851 NE GRANGER AVE
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-9672
Mailing Address - Country:US
Mailing Address - Phone:541-231-3439
Mailing Address - Fax:
Practice Address - Street 1:744 NW 4TH ST
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-6415
Practice Address - Country:US
Practice Address - Phone:541-231-3439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-09
Last Update Date:2019-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR75641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical