Provider Demographics
NPI:1295223923
Name:ROMINE, CASEY
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:ROMINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16232 SW LOWER BRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:TERREBONNE
Mailing Address - State:OR
Mailing Address - Zip Code:97760-9678
Mailing Address - Country:US
Mailing Address - Phone:541-410-8713
Mailing Address - Fax:
Practice Address - Street 1:16232 SW LOWER BRIDGE WAY
Practice Address - Street 2:
Practice Address - City:TERREBONNE
Practice Address - State:OR
Practice Address - Zip Code:97760-9678
Practice Address - Country:US
Practice Address - Phone:541-316-0206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-27
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC6145101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500756496Medicaid