Provider Demographics
NPI:1356571194
Name:GLENN T. BRASINGTON, PH.D., INC.
Entity type:Organization
Organization Name:GLENN T. BRASINGTON, PH.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRASINGTN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-310-9157
Mailing Address - Street 1:PO BOX 962
Mailing Address - Street 2:
Mailing Address - City:SILVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97381-0962
Mailing Address - Country:US
Mailing Address - Phone:503-310-9157
Mailing Address - Fax:503-873-6340
Practice Address - Street 1:429 N WATER ST
Practice Address - Street 2:
Practice Address - City:SILVERTON
Practice Address - State:OR
Practice Address - Zip Code:97381-1645
Practice Address - Country:US
Practice Address - Phone:503-310-9157
Practice Address - Fax:503-873-6340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-14
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI211103TC1900X
OR856103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
R000TCHMFOtherMEDICARE- UNSPECIFIED