Basic Information
| Provider Information | |||||||||
| NPI: | 1699355255 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CISERO BLUMBERG | ||||||||
| FirstName: | LEA | ||||||||
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| Credential: | QMHP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1710 | ||||||||
| Address2: | |||||||||
| City: | REDMOND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977560516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415164087 | ||||||||
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| Practice Location | |||||||||
| Address1: | 908 NE 4TH ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977014646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416177365 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2021 | ||||||||
| LastUpdateDate: | 04/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 21-QMHP-R-0608 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.