Basic Information
| Provider Information | |||||||||
| NPI: | 1538365978 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KAHLE | ||||||||
| FirstName: | BRENTON | ||||||||
| MiddleName: | DEAN | ||||||||
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| Credential: | M.S., MFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 418 PLEASANT AVE | ||||||||
| Address2: | |||||||||
| City: | ASTORIA | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971035730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033255731 | ||||||||
| FaxNumber: | 5033255731 | ||||||||
| Practice Location | |||||||||
| Address1: | 4422 NE DEVILS LAKE BLVD | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | LINCOLN CITY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973675000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412654196 | ||||||||
| FaxNumber: | 5419941882 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2007 | ||||||||
| LastUpdateDate: | 05/09/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | T0501 | OR | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.