Healthcare Provider Details

I. General information

NPI: 1487129557
Provider Name (Legal Business Name): CAITLIN M SPECK PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2018
Last Update Date: 11/09/2022
Certification Date: 11/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

376 SW BLUFF DR STE 5
BEND OR
97702-1399
US

IV. Provider business mailing address

376 SW BLUFF DR STE 5
BEND OR
97702-1399
US

V. Phone/Fax

Practice location:
  • Phone: 458-281-0413
  • Fax:
Mailing address:
  • Phone: 458-281-0413
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number3003
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3003
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: