Healthcare Provider Details

I. General information

NPI: 1124532643
Provider Name (Legal Business Name): ROBERT L NUTTING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2017
Last Update Date: 11/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3157 RAINBOW LN
EAGLE POINT OR
97524-9638
US

IV. Provider business mailing address

3157 RAINBOW LN
EAGLE POINT OR
97524-9638
US

V. Phone/Fax

Practice location:
  • Phone: 541-660-5714
  • Fax:
Mailing address:
  • Phone: 541-660-5714
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberL5127
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number13488
License Number StateOR

VIII. Authorized Official

Name: ROBERT L NUTTING
Title or Position: CLINICAL SOCIAL WORKER/BODY WORKER
Credential: MSW, LCSW, LMT
Phone: 541-660-5714