Provider Demographics
NPI:1780053314
Name:DISMUKE, CHANEL BREAE (PSYD)
Entity type:Individual
Prefix:
First Name:CHANEL
Middle Name:BREAE
Last Name:DISMUKE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1975 NW 167TH PL STE 100-42
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-4908
Mailing Address - Country:US
Mailing Address - Phone:503-436-5663
Mailing Address - Fax:
Practice Address - Street 1:1975 NW 167TH PL STE 100-42
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-4908
Practice Address - Country:US
Practice Address - Phone:503-436-5663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-24
Last Update Date:2024-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TB0200X
OR3292103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical