Healthcare Provider Details

I. General information

NPI: 1841155629
Provider Name (Legal Business Name): ANGUELINA KOUZNETSOVA LMT
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2025
Last Update Date: 12/23/2025
Certification Date: 12/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63152 DESERT SAGE ST
BEND OR
97701-7710
US

IV. Provider business mailing address

63152 DESERT SAGE ST
BEND OR
97701-7710
US

V. Phone/Fax

Practice location:
  • Phone: 541-390-6736
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number023060
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: