Provider Demographics
NPI:1619568243
Name:BREVIK, KILEY
Entity Type:Individual
Prefix:
First Name:KILEY
Middle Name:
Last Name:BREVIK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14800 NW CORNELL RD APT 27B
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-5484
Mailing Address - Country:US
Mailing Address - Phone:425-478-2135
Mailing Address - Fax:
Practice Address - Street 1:14800 NW CORNELL RD APT 27B
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-5484
Practice Address - Country:US
Practice Address - Phone:425-478-2135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-27
Last Update Date:2024-03-29
Deactivation Date:2021-08-09
Deactivation Code:
Reactivation Date:2021-10-05
Provider Licenses
StateLicense IDTaxonomies
OR101YM0800X
106E00000X, 106S00000X
ORR8642101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician