Provider Demographics
NPI:1649544677
Name:DIPASQUALE, BRANDI MAXINE (MACOM, LAC)
Entity type:Individual
Prefix:
First Name:BRANDI
Middle Name:MAXINE
Last Name:DIPASQUALE
Suffix:
Gender:F
Credentials:MACOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5123 NE 32ND PL
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-6943
Mailing Address - Country:US
Mailing Address - Phone:802-309-5105
Mailing Address - Fax:
Practice Address - Street 1:5123 NE 32ND PL
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-6943
Practice Address - Country:US
Practice Address - Phone:802-309-5105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-08
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC153483171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist