Provider Demographics
NPI:1427642644
Name:BROOKMYER, SAMUEL KEVIN
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:KEVIN
Last Name:BROOKMYER
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 1:15174 SE ASTON LOOP
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-7875
Mailing Address - Country:US
Mailing Address - Phone:503-701-3371
Mailing Address - Fax:
Practice Address - Street 1:15174 SE ASTON LOOP
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236-7875
Practice Address - Country:US
Practice Address - Phone:503-701-3371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-28
Last Update Date:2021-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst