Healthcare Provider Details

I. General information

NPI: 1265084263
Provider Name (Legal Business Name): CHRISTINA L CANNON RADT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2019
Last Update Date: 05/04/2022
Certification Date: 05/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63311 JAMISON ST
BEND OR
97703-8288
US

IV. Provider business mailing address

2577 NE COURTNEY DR
BEND OR
97701-7752
US

V. Phone/Fax

Practice location:
  • Phone: 541-332-7500
  • Fax: 541-322-7565
Mailing address:
  • Phone: 541-332-7500
  • Fax: 541-322-7565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1353740719
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: