Provider Demographics
NPI:1811500762
Name:BROWN, KRISTA DAWN
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:DAWN
Last Name:BROWN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTA
Other - Middle Name:DAWN
Other - Last Name:TRAHERN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2577 NE COURTNEY DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-7752
Mailing Address - Country:US
Mailing Address - Phone:541-322-7500
Mailing Address - Fax:541-322-7565
Practice Address - Street 1:63311 JAMISON ST
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-8288
Practice Address - Country:US
Practice Address - Phone:541-322-7500
Practice Address - Fax:541-322-7565
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
OR21-QMHA-R-1295171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist