Provider Demographics
NPI:1285124545
Name:PETRIE, TODD BRADLEY
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:BRADLEY
Last Name:PETRIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 16756
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97292-0756
Mailing Address - Country:US
Mailing Address - Phone:503-374-3730
Mailing Address - Fax:503-208-2596
Practice Address - Street 1:7916 SE FOSTER RD STE 201
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-4289
Practice Address - Country:US
Practice Address - Phone:503-374-3730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-12
Last Update Date:2018-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17-CRM-013175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist