Healthcare Provider Details

I. General information

NPI: 1265952451
Provider Name (Legal Business Name): BONNIE THIELKE TEMPLE MA, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2017
Last Update Date: 06/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 COUNTRY CLUB RD STE 222
EUGENE OR
97401-2238
US

IV. Provider business mailing address

385 51ST ST
SPRINGFIELD OR
97478-6025
US

V. Phone/Fax

Practice location:
  • Phone: 541-686-6000
  • Fax: 541-344-8239
Mailing address:
  • Phone: 541-556-7681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberR4797
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: