Provider Demographics
NPI:1235498536
Name:FRIDERES, KYLIE JEANE BAUER (MA)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:JEANE BAUER
Last Name:FRIDERES
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60748 RIVER BEND DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-7909
Mailing Address - Country:US
Mailing Address - Phone:360-690-5264
Mailing Address - Fax:
Practice Address - Street 1:731 NW FRANKLIN AVE STE 107
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703
Practice Address - Country:US
Practice Address - Phone:541-306-1128
Practice Address - Fax:541-647-1162
Is Sole Proprietor?:No
Enumeration Date:2012-05-08
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC4603101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR123190Medicaid