Healthcare Provider Details

I. General information

NPI: 1417045469
Provider Name (Legal Business Name): ROGER ALLEN KRYZANEK L.C.S.W.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

336 NE NORTON AVE STE 4
BEND OR
97701-4350
US

IV. Provider business mailing address

PO BOX 7334
BEND OR
97708-7334
US

V. Phone/Fax

Practice location:
  • Phone: 541-382-8870
  • Fax: 541-382-8870
Mailing address:
  • Phone: 541-382-8870
  • Fax: 541-382-8870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL0154
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: