Healthcare Provider Details

I. General information

NPI: 1831316835
Provider Name (Legal Business Name): KEN J. BRINKER RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

722 NE 162ND AVE
PORTLAND OR
97230-5760
US

IV. Provider business mailing address

722 NE 162ND AVE
PORTLAND OR
97230-5760
US

V. Phone/Fax

Practice location:
  • Phone: 503-408-5016
  • Fax:
Mailing address:
  • Phone: 503-408-5016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: