Provider Demographics
NPI:1801773361
Name:BROCKBERG, AVERY AARON (OTD, OTR/L)
Entity type:Individual
Prefix:
First Name:AVERY
Middle Name:AARON
Last Name:BROCKBERG
Suffix:
Gender:M
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 NW UPTOWN TER UNIT 2B
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-5558
Mailing Address - Country:US
Mailing Address - Phone:605-760-1074
Mailing Address - Fax:
Practice Address - Street 1:8285 SW NIMBUS AVE STE 174
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97008-6447
Practice Address - Country:US
Practice Address - Phone:503-579-7327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-18
Last Update Date:2025-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR537257225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist