Healthcare Provider Details

I. General information

NPI: 1710528989
Provider Name (Legal Business Name): CONNIE J KERSENBROCK, LCSW
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2019
Last Update Date: 09/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 SE REED MARKET RD STE 110
BEND OR
97702-2237
US

IV. Provider business mailing address

130 SW CANYON DR APT 3
REDMOND OR
97756-2054
US

V. Phone/Fax

Practice location:
  • Phone: 620-966-6925
  • Fax:
Mailing address:
  • Phone: 620-966-6925
  • 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: CONNIE KERSENBROCK
Title or Position: OWNER
Credential: LCSW
Phone: 620-966-6925