Healthcare Provider Details

I. General information

NPI: 1053543066
Provider Name (Legal Business Name): NATHANIEL KRAVITZ RN, MN, PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2009
Last Update Date: 07/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2045 SILVERTON RD NE
SALEM OR
97301-0100
US

IV. Provider business mailing address

1587 PACIFIC RIDGE LN SE
JEFFERSON OR
97352-9654
US

V. Phone/Fax

Practice location:
  • Phone: 503-588-5351
  • Fax: 503-585-4908
Mailing address:
  • Phone: 503-361-7758
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number201050130NP
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number23426
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number200841283RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: