Healthcare Provider Details

I. General information

NPI: 1043753916
Provider Name (Legal Business Name): MARIO SANTINO BUGNONE LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2016
Last Update Date: 07/09/2025
Certification Date: 07/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2136 ASH ST
NORTH BEND OR
97459-2118
US

IV. Provider business mailing address

2136 ASH ST
NORTH BEND OR
97459-2118
US

V. Phone/Fax

Practice location:
  • Phone: 928-380-1120
  • Fax:
Mailing address:
  • Phone: 928-380-1120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.2102756
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberI.2102756
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: