Healthcare Provider Details

I. General information

NPI: 1780697144
Provider Name (Legal Business Name): GLENN TAYLOR BRASINGTON PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2006
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 TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number856
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number211
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: