Provider Demographics
NPI:1902378003
Name:IMPERIAL, BRANDIE LYNNE (LCSW, CADCI)
Entity Type:Individual
Prefix:
First Name:BRANDIE
Middle Name:LYNNE
Last Name:IMPERIAL
Suffix:
Gender:F
Credentials:LCSW, CADCI
Other - Prefix:
Other - First Name:BRANDIE
Other - Middle Name:LYNNE
Other - Last Name:FAZAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW, CADCI
Mailing Address - Street 1:10175 SW BARBUR BLVD STE 204B
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-5953
Mailing Address - Country:US
Mailing Address - Phone:971-666-1290
Mailing Address - Fax:503-914-1736
Practice Address - Street 1:10175 SW BARBUR BLVD STE 204B
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-5953
Practice Address - Country:US
Practice Address - Phone:971-666-1290
Practice Address - Fax:503-914-1736
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-30
Last Update Date:2018-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL67541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical