Provider Demographics
NPI:1972820405
Name:KRAVITZ, ROBERT B (CACD-I)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:B
Last Name:KRAVITZ
Suffix:
Gender:M
Credentials:CACD-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:461 NE GREENWOOD AVE
Mailing Address - Street 2:STE A
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-4607
Mailing Address - Country:US
Mailing Address - Phone:541-617-7365
Mailing Address - Fax:541-312-6343
Practice Address - Street 1:461 NE GREENWOOD AVE
Practice Address - Street 2:STE A
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4607
Practice Address - Country:US
Practice Address - Phone:541-617-7365
Practice Address - Fax:541-312-6343
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-23
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR09-P-06101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR210831Medicaid