Provider Demographics
NPI:1215319330
Name:ATHERTON, BRENNAN DALE (PHD)
Entity type:Individual
Prefix:DR
First Name:BRENNAN
Middle Name:DALE
Last Name:ATHERTON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 S 4TH ST STE 401
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4715
Mailing Address - Country:US
Mailing Address - Phone:701-795-3000
Mailing Address - Fax:801-373-0639
Practice Address - Street 1:151 S 4TH ST STE 401
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4715
Practice Address - Country:US
Practice Address - Phone:701-795-3000
Practice Address - Fax:801-373-0639
Is Sole Proprietor?:No
Enumeration Date:2015-06-25
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND585103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical