Provider Demographics
NPI:1922580778
Name:ANSOTEGUI, BROOKE
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:ANSOTEGUI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 NE BOARDMAN AVE
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OR
Mailing Address - Zip Code:97818-9703
Mailing Address - Country:US
Mailing Address - Phone:541-561-7039
Mailing Address - Fax:
Practice Address - Street 1:11740 SW 68TH PKWY STE 200
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-9058
Practice Address - Country:US
Practice Address - Phone:541-561-7039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-29
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101YM0800X
ORR8873101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty