Healthcare Provider Details

I. General information

NPI: 1245928902
Provider Name (Legal Business Name): KENDRA VITA LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2023
Last Update Date: 04/28/2023
Certification Date: 04/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 LAWRENCE ST
EUGENE OR
97401-2828
US

IV. Provider business mailing address

815 LAWRENCE ST APT 10
EUGENE OR
97401-2868
US

V. Phone/Fax

Practice location:
  • Phone: 541-968-3032
  • Fax:
Mailing address:
  • Phone: 541-968-3032
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC7354
License Number StateOR

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: