Provider Demographics
NPI:1124768593
Name:DESILETS, KRISTEN ANN
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:ANN
Last Name:DESILETS
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:PO BOX 453
Mailing Address - Street 2:
Mailing Address - City:HINES
Mailing Address - State:OR
Mailing Address - Zip Code:97738-0453
Mailing Address - Country:US
Mailing Address - Phone:541-413-0483
Mailing Address - Fax:
Practice Address - Street 1:1200 HILYARD ST STE 450
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-8164
Practice Address - Country:US
Practice Address - Phone:458-205-7131
Practice Address - Fax:458-205-7061
Is Sole Proprietor?:No
Enumeration Date:2022-03-31
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
ORTHW000108865101YM0800X, 175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health