=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275869661
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TONI BLEICK DNP PMHNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2009
-----------------------------------------------------
Last Update Date | 07/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 724 S CENTRAL AVE STE 101
-----------------------------------------------------
City | MEDFORD
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97501-7808
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-249-7724
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 43693 HIGHWAY 62
-----------------------------------------------------
City | PROSPECT
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97536-9753
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-910-4962
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WC1500X
-----------------------------------------------------
Taxonomy Name | Community Health Registered Nurse
-----------------------------------------------------
License Number | 200742260RN
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number | 200742260RN
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 10030415
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------