Healthcare Provider Details

I. General information

NPI: 1760918619
Provider Name (Legal Business Name): ABIGAIL BRUNTLETT LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 12/20/2022
Certification Date: 12/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 SW DISK DR STE 104
BEND OR
97702-3385
US

IV. Provider business mailing address

PO BOX 535
BEND OR
97709-0535
US

V. Phone/Fax

Practice location:
  • Phone: 541-316-5574
  • Fax:
Mailing address:
  • Phone: 541-214-4291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC7022
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC7022
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: