Healthcare Provider Details

I. General information

NPI: 1558994335
Provider Name (Legal Business Name): KELLIE KREITZBERG, LCSW LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2020
Last Update Date: 02/19/2020
Certification Date: 02/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

374 W 12TH AVE STE 2
EUGENE OR
97401-3449
US

IV. Provider business mailing address

374 W 12TH AVE STE 2
EUGENE OR
97401-3449
US

V. Phone/Fax

Practice location:
  • Phone: 541-520-8142
  • Fax:
Mailing address:
  • Phone:
  • 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: KELLIE KREITZBERG
Title or Position: OWNER/LCSW
Credential: LCSW
Phone: 541-520-8142