Healthcare Provider Details

I. General information

NPI: 1730898925
Provider Name (Legal Business Name): CHRYSTAIL CUELLAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2022
Last Update Date: 11/03/2023
Certification Date: 11/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 NW 5TH ST
REDMOND OR
97756-1869
US

IV. Provider business mailing address

PO BOX 1710
REDMOND OR
97756-0516
US

V. Phone/Fax

Practice location:
  • Phone: 541-504-2218
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: