Provider Demographics
NPI:1588976559
Name:DRISCOLL, CHANDA MAUREEN (LCSW)
Entity type:Individual
Prefix:
First Name:CHANDA
Middle Name:MAUREEN
Last Name:DRISCOLL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 SW COLUMBIA ST
Mailing Address - Street 2:SUITE 6210
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-1099
Mailing Address - Country:US
Mailing Address - Phone:541-383-3005
Mailing Address - Fax:
Practice Address - Street 1:2965 NE CONNERS AVE
Practice Address - Street 2:SUITE 280
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-7753
Practice Address - Country:US
Practice Address - Phone:541-323-4269
Practice Address - Fax:541-383-1883
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-07
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK5961041C0700X
ORL61541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500708564Medicaid
OR500708564Medicaid