Provider Demographics
NPI:1700164878
Name:ACT II PSYCHOLOGY, INC.
Entity Type:Organization
Organization Name:ACT II PSYCHOLOGY, INC.
Other - Org Name:N/A
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:CORY
Authorized Official - Last Name:BRILLHART
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:503-400-7500
Mailing Address - Street 1:189 LIBERTY ST., SE, SUITE 210A
Mailing Address - Street 2:THE REED OPERA HOUSE
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301
Mailing Address - Country:US
Mailing Address - Phone:503-400-7500
Mailing Address - Fax:503-581-1069
Practice Address - Street 1:189 LIBERTY ST., SE, SUITE 210A
Practice Address - Street 2:THE REED OPERA HOUSE
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301
Practice Address - Country:US
Practice Address - Phone:503-400-7500
Practice Address - Fax:503-581-1069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-23
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2162261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR12252868OtherCAQH