Healthcare Provider Details

I. General information

NPI: 1619712148
Provider Name (Legal Business Name): MUSTANG MAGIC EQUINE THERAPY SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2024
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62239 POWELL BUTTE HWY
BEND OR
97701-9355
US

IV. Provider business mailing address

62239 POWELL BUTTE HWY
BEND OR
97701-9355
US

V. Phone/Fax

Practice location:
  • Phone: 541-204-1079
  • Fax:
Mailing address:
  • Phone: 541-204-1079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: ANNETTE PELLETIER
Title or Position: OWNER/CLINICIAN
Credential: LCSW
Phone: 541-204-1079