Healthcare Provider Details

I. General information

NPI: 1700612934
Provider Name (Legal Business Name): KRISTIN MATHES CLINICAL MENTAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2024
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1622 NW AWBREY RD
BEND OR
97703-1833
US

IV. Provider business mailing address

70 SW CENTURY DR SET 100 PMB 5040
BEND OR
97702
US

V. Phone/Fax

Practice location:
  • Phone: 920-286-2316
  • Fax:
Mailing address:
  • Phone: 920-286-2316
  • 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: KRISTIN MARIE MATHES
Title or Position: OWNER
Credential: LCSW
Phone: 920-286-2316