Healthcare Provider Details

I. General information

NPI: 1841936531
Provider Name (Legal Business Name): CRYSTAL TANNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2022
Last Update Date: 04/25/2025
Certification Date: 04/25/2025
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: 541-516-4087
  • Fax:
Mailing address:
  • Phone: 541-516-4087
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberT-22-1608
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number201130008LPN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: