Healthcare Provider Details

I. General information

NPI: 1356571194
Provider Name (Legal Business Name): GLENN T. BRASINGTON, PH.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2009
Last Update Date: 07/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

429 N WATER ST
SILVERTON OR
97381-1645
US

IV. Provider business mailing address

PO BOX 962
SILVERTON OR
97381-0962
US

V. Phone/Fax

Practice location:
  • Phone: 503-310-9157
  • Fax: 503-873-6340
Mailing address:
  • Phone: 503-310-9157
  • Fax: 503-873-6340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number211
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number856
License Number StateOR

VIII. Authorized Official

Name: GLENN BRASINGTN
Title or Position: PRESIDENT
Credential:
Phone: 503-310-9157