Provider Demographics
NPI:1063128916
Name:BRANCH, MITCHELL S (CRM)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:S
Last Name:BRANCH
Suffix:
Gender:M
Credentials:CRM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1817 NE 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-3960
Mailing Address - Country:US
Mailing Address - Phone:503-719-7985
Mailing Address - Fax:503-994-5262
Practice Address - Street 1:1817 NE 6TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-3960
Practice Address - Country:US
Practice Address - Phone:503-719-7985
Practice Address - Fax:503-994-5262
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR22-CRM-1540261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR999999Medicaid