Healthcare Provider Details

I. General information

NPI: 1427499656
Provider Name (Legal Business Name): MOLLIE ELIZABETH CUDMORE MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2013
Last Update Date: 01/04/2024
Certification Date: 01/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62606 HURRICANE CREEK RD
JOSEPH OR
97846-8109
US

IV. Provider business mailing address

62606 HURRICANE CREEK RD
JOSEPH OR
97846-8109
US

V. Phone/Fax

Practice location:
  • Phone: 541-805-1606
  • Fax:
Mailing address:
  • Phone: 541-805-1606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier1020986
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: