Healthcare Provider Details

I. General information

NPI: 1841044534
Provider Name (Legal Business Name): IAN WELLES KEUSINK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2024
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1308 E 1ST ST STE 3
NEWBERG OR
97132-2942
US

IV. Provider business mailing address

851 NE BAKER ST
MCMINNVILLE OR
97128-4991
US

V. Phone/Fax

Practice location:
  • Phone: 503-554-5007
  • Fax:
Mailing address:
  • Phone: 503-435-4840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberR9290
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: