Healthcare Provider Details

I. General information

NPI: 1447972757
Provider Name (Legal Business Name): FAWN NEWPORT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2022
Last Update Date: 09/07/2023
Certification Date: 09/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 S J ST
LAKEVIEW OR
97630-1623
US

IV. Provider business mailing address

700 S J ST
LAKEVIEW OR
97630-1623
US

V. Phone/Fax

Practice location:
  • Phone: 541-947-2114
  • Fax:
Mailing address:
  • Phone: 541-947-2114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: