Healthcare Provider Details

I. General information

NPI: 1477196087
Provider Name (Legal Business Name): LYNETTE ROBERTS CADC1, CRM, PSS,QMHA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2019
Last Update Date: 11/18/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

908 NE 4TH ST
BEND OR
97701-4646
US

IV. Provider business mailing address

908 NE 4TH ST
BEND OR
97701-4646
US

V. Phone/Fax

Practice location:
  • Phone: 541-617-7365
  • Fax: 541-312-6343
Mailing address:
  • Phone: 541-617-7365
  • Fax: 541-312-6343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number210710194
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number23-QMHA-R-3797
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number18-CRM-371
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: