Basic Information
| Provider Information | |||||||||
| NPI: | 1750780268 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KWAISER | ||||||||
| FirstName: | MANDY | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | B.S. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 365 NE COURT ST | ||||||||
| Address2: | |||||||||
| City: | PRINEVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977541936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413235330 | ||||||||
| FaxNumber: | 5414476694 | ||||||||
| Practice Location | |||||||||
| Address1: | 365 NE COURT ST | ||||||||
| Address2: | |||||||||
| City: | PRINEVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977541936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413235330 | ||||||||
| FaxNumber: | 5414476694 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2014 | ||||||||
| LastUpdateDate: | 08/20/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 283234 | 05 | OR | MEDICAID |