Healthcare Provider Details

I. General information

NPI: 1669998266
Provider Name (Legal Business Name): LIFE BALANCE BEND LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 SW COLORADO AVE STE 350
BEND OR
97702-1130
US

IV. Provider business mailing address

15 SW COLORADO AVE STE 350
BEND OR
97702-1130
US

V. Phone/Fax

Practice location:
  • Phone: 541-306-1898
  • Fax:
Mailing address:
  • Phone: 541-306-1898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3873
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4289
License Number StateOR

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MR. TRAVIS SAMMON
Title or Position: CO-OWNER
Credential: LCSW
Phone: 541-306-1898