Healthcare Provider Details

I. General information

NPI: 1396332755
Provider Name (Legal Business Name): AMANDA CASSANDRA ANANIAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: AMANDA CASSANDRA FRUMENTO

II. Dates (important events)

Enumeration Date: 12/30/2020
Last Update Date: 04/07/2022
Certification Date: 04/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21281 DARNEL AVE
BEND OR
97702-9579
US

IV. Provider business mailing address

21281 DARNEL AVE
BEND OR
97702-9579
US

V. Phone/Fax

Practice location:
  • Phone: 541-801-5100
  • Fax:
Mailing address:
  • Phone: 541-299-2981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL10689
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: