Healthcare Provider Details

I. General information

NPI: 1215319330
Provider Name (Legal Business Name): BRENNAN DALE ATHERTON PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2015
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1309 11TH ST W APT 208
WILLISTON ND
58801-4654
US

IV. Provider business mailing address

1309 11TH ST W APT 208
WILLISTON ND
58801-4654
US

V. Phone/Fax

Practice location:
  • Phone: 801-717-0405
  • Fax:
Mailing address:
  • Phone: 801-717-0405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number585
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: