Basic Information
| Provider Information | |||||||||
| NPI: | 1477833390 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROOKS | ||||||||
| FirstName: | SUMNER | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MPH, RD, CSSD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 847 NE 19TH AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972322684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039632801 | ||||||||
| FaxNumber: | 5039632825 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 NE 99TH AVE | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972209428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039632707 | ||||||||
| FaxNumber: | 5039632802 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2011 | ||||||||
| LastUpdateDate: | 10/14/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 987508 | CA | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 133V00000X | LD-D-10169435 | OR | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 2065312 | 05 | WA | MEDICAID | 500714219 | 05 | OR | MEDICAID |