Healthcare Provider Details

I. General information

NPI: 1548654031
Provider Name (Legal Business Name): TAWNYA FREUDENTHALER CADCI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TAWNYA BAKER CADCI

II. Dates (important events)

Enumeration Date: 03/24/2015
Last Update Date: 04/27/2022
Certification Date: 04/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

418 SW 6TH STREET
GRANTS PASS OR
97526
US

IV. Provider business mailing address

418 SW 6TH ST
GRANTS PASS OR
97526
US

V. Phone/Fax

Practice location:
  • Phone: 541-450-9615
  • Fax:
Mailing address:
  • Phone: 541-450-9615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number93-1200332
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number16-02-19
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier1871703702
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: