Provider Demographics
NPI:1356543094
Name:PILLING, BREK (PHD)
Entity type:Individual
Prefix:
First Name:BREK
Middle Name:
Last Name:PILLING
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:PO BOX 1657
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83303-1657
Mailing Address - Country:US
Mailing Address - Phone:208-734-3356
Mailing Address - Fax:208-733-9463
Practice Address - Street 1:1918 OVERLAND AVE
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2439
Practice Address - Country:US
Practice Address - Phone:208-219-0211
Practice Address - Fax:208-733-9463
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY202122103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1684719Medicare ID - Type Unspecified