Provider Demographics
NPI:1447631783
Name:BRODEUR, ALLISON
Entity type:Individual
Prefix:
First Name:ALLISON
Middle Name:
Last Name:BRODEUR
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 1:6380 NE CHERRY DR APT 635
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-7462
Mailing Address - Country:US
Mailing Address - Phone:860-302-5123
Mailing Address - Fax:
Practice Address - Street 1:1411 SW MORRISON ST STE 310
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-1945
Practice Address - Country:US
Practice Address - Phone:860-302-5123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-12
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTLPC101Y00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor