Healthcare Provider Details

I. General information

NPI: 1073686853
Provider Name (Legal Business Name): SUSAN MARIE WENDELBORG L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 11/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 E 11TH AVE
EUGENE OR
97401-3511
US

IV. Provider business mailing address

1863 PIONEER PKWY E #441
SPRINGFIELD OR
97477-3907
US

V. Phone/Fax

Practice location:
  • Phone: 773-213-1392
  • Fax: 541-722-7033
Mailing address:
  • Phone: 773-213-1392
  • Fax: 541-722-7033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.008435
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL5896
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier1627533
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerBCBS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: