Provider Demographics
NPI:1821608548
Name:GOETTE, BROOKE NICOLE
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:NICOLE
Last Name:GOETTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2943 SE ALDER ST APT 17
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-3087
Mailing Address - Country:US
Mailing Address - Phone:336-848-1307
Mailing Address - Fax:
Practice Address - Street 1:1675 SW MARLOW AVE STE 200
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5102
Practice Address - Country:US
Practice Address - Phone:971-248-2395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-06
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORABA-NI-10205004106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician