Healthcare Provider Details

I. General information

NPI: 1275991077
Provider Name (Legal Business Name): MARY JANE IIDA CADC II
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2016
Last Update Date: 03/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1651 CENTENNIAL BLVD
SPRINGFIELD OR
97477-3363
US

IV. Provider business mailing address

687 CHESHIRE AVE
EUGENE OR
97402-5060
US

V. Phone/Fax

Practice location:
  • Phone: 541-762-4532
  • Fax: 541-762-2467
Mailing address:
  • Phone: 541-684-4148
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number18-04-15
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: