Provider Demographics
NPI:1639279318
Name:KERSENBROCK, CONNIE J (LCSW)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:J
Last Name:KERSENBROCK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:J
Other - Last Name:KERSENBROCK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:2330 NE DIVISION ST STE 9B
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-3530
Mailing Address - Country:US
Mailing Address - Phone:541-323-5332
Mailing Address - Fax:541-323-5854
Practice Address - Street 1:2330 NE DIVISION ST STE 9B
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-3530
Practice Address - Country:US
Practice Address - Phone:541-323-5332
Practice Address - Fax:541-323-5854
Is Sole Proprietor?:No
Enumeration Date:2006-09-23
Last Update Date:2018-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS3576101YM0800X, 1041C0700X
OR74051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health