Healthcare Provider Details

I. General information

NPI: 1073251856
Provider Name (Legal Business Name): CRYSTAL ANNAMARIE BRUCE QMHA-R
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2022
Last Update Date: 05/23/2022
Certification Date: 05/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1435 G ST
SPRINGFIELD OR
97477-4113
US

IV. Provider business mailing address

PO BOX 163
SPRINGFIELD OR
97477-0024
US

V. Phone/Fax

Practice location:
  • Phone: 541-735-9420
  • Fax:
Mailing address:
  • Phone: 541-735-9420
  • Fax: 541-747-9870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number21-QMHA-R-1519
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: