Healthcare Provider Details

I. General information

NPI: 1942022256
Provider Name (Legal Business Name): SHAYLA WITTENBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2024
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

373 NE GREENWOOD AVE
BEND OR
97701-4605
US

IV. Provider business mailing address

2051 NW NICKERNUT AVE
REDMOND OR
97756-7757
US

V. Phone/Fax

Practice location:
  • Phone: 541-343-1728
  • Fax:
Mailing address:
  • Phone: 541-797-0748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: