Provider Demographics
NPI:1700170818
Name:BRILLHART, DAVID CORY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:CORY
Last Name:BRILLHART
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:189 LIBERTY ST., NE, 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., NE, 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
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-06
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2162103T00000X, 103TB0200X, 103TC0700X, 103TC1900X, 103TF0000X, 103TF0200X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR160160Medicare UPIN