Provider Demographics
NPI:1053095307
Name:PARKER, BREDE EDGAR MARTIN (PSYD)
Entity type:Individual
Prefix:
First Name:BREDE
Middle Name:EDGAR MARTIN
Last Name:PARKER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6501 REED RD APT 309
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-2237
Mailing Address - Country:US
Mailing Address - Phone:815-383-8454
Mailing Address - Fax:
Practice Address - Street 1:3050 SE DIVISION ST STE 215
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1997
Practice Address - Country:US
Practice Address - Phone:503-622-8964
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist