Provider Demographics
NPI:1780697144
Name:BRASINGTON, GLENN TAYLOR (PHD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:TAYLOR
Last Name:BRASINGTON
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 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
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR856103TC1900X
HI211103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR000TCHMFOtherMEDICARE-TYPE UNSPECIFIED
OROOOTCHMF62Medicare ID - Type Unspecified