Provider Demographics
NPI:1023460102
Name:MOORE, BRENNON PATRICK (CADC-II, LPC, LMHC)
Entity type:Individual
Prefix:
First Name:BRENNON
Middle Name:PATRICK
Last Name:MOORE
Suffix:
Gender:M
Credentials:CADC-II, LPC, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 NW BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-2615
Mailing Address - Country:US
Mailing Address - Phone:541-980-7542
Mailing Address - Fax:
Practice Address - Street 1:835 NW BOND ST STE 100
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703
Practice Address - Country:US
Practice Address - Phone:541-980-7542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-12
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60571272101YM0800X
ORC3918101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health