Provider Demographics
NPI:1366231037
Name:BRAVE SOULS
Entity type:Organization
Organization Name:BRAVE SOULS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF BRAVE SOULS
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:MCABEE
Authorized Official - Suffix:
Authorized Official - Credentials:CADC-2 QMHA-2
Authorized Official - Phone:541-295-5185
Mailing Address - Street 1:6135 SW CHERRYHILL DR
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97008-4446
Mailing Address - Country:US
Mailing Address - Phone:541-295-5185
Mailing Address - Fax:
Practice Address - Street 1:6135 SW CHERRYHILL DR
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97008-4446
Practice Address - Country:US
Practice Address - Phone:541-295-5185
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-01
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1871105684Medicaid
OR1740843689Medicaid
OR1982431110Medicaid