Healthcare Provider Details

I. General information

NPI: 1922268614
Provider Name (Legal Business Name): MR. EDWARD ALEX PLACENCIA III
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2008
Last Update Date: 06/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1790 W 11TH AVE STE 290
EUGENE OR
97402-3759
US

IV. Provider business mailing address

1918 PORT ST
EUGENE OR
97402-1105
US

V. Phone/Fax

Practice location:
  • Phone: 541-686-1262
  • Fax: 541-686-0359
Mailing address:
  • Phone: 541-689-0427
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

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: