Healthcare Provider Details

I. General information

NPI: 1932303351
Provider Name (Legal Business Name): SUSAN ANNA BERNAVICH B.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

913 NW GARDEN VALLEY BLVD
ROSEBURG OR
97470-6523
US

IV. Provider business mailing address

PO BOX 1778
SUTHERLIN OR
97479-1778
US

V. Phone/Fax

Practice location:
  • Phone: 541-440-1000
  • Fax:
Mailing address:
  • Phone: 541-459-7503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: