Provider Demographics
NPI:1730554163
Name:FOSBERG, DAVE
Entity type:Individual
Prefix:
First Name:DAVE
Middle Name:
Last Name:FOSBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 NE NORTON AVE
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-4310
Mailing Address - Country:US
Mailing Address - Phone:541-213-1699
Mailing Address - Fax:
Practice Address - Street 1:23 NW GREENWOOD AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-2078
Practice Address - Country:US
Practice Address - Phone:541-383-4293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-10
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker