Healthcare Provider Details

I. General information

NPI: 1356374706
Provider Name (Legal Business Name): POSITIVE POTENTIAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

336 NE NORTON AVE SUITE 3
BEND OR
97701-4350
US

IV. Provider business mailing address

336 NE NORTON AVE SUITE 3
BEND OR
97701-4350
US

V. Phone/Fax

Practice location:
  • Phone: 541-312-3090
  • Fax: 541-317-8488
Mailing address:
  • Phone: 541-312-3090
  • Fax: 541-317-8488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL3116
License Number StateOR

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MS. JUDITH MARIE BOONE
Title or Position: PRESIDENT
Credential: LCSW
Phone: 541-312-3090