Individual
COLLAINE BROOKE FADDIS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LMT
Contact information
Practice address
4512 SE WOODSTOCK BLVD, PORTLAND, OR 97206-6274
(503) 777-2776
Mailing address
3031 SE 53RD AVE, PORTLAND, OR 97206-2119
(503) 810-4941
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
14317
OR
Other
Enumeration date
09/20/2007
Last updated
09/20/2007
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