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General NPI Number Information
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NPI Number | 1699286591
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Entity Type | Organization
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Legal Business Name | OREGON EMDR LLC
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Dates
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Enumeration Date | 10/18/2017
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Last Update Date | 10/18/2017
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Provider Practice Location Address
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Address Line | 175 W B ST
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City | SPRINGFIELD
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State | OR
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Zip | 97477-4575
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Country | US
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Telephone | 541-525-9416
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Fax | 541-722-7033
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Provider Business Mailing Address
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Address Line | 1863 PIONEER PKWY E
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City | SPRINGFIELD
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State | OR
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Zip | 97477-3907
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | SUSAN MARIE WENDELBORG
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Credential | LCSW
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Telephone | 541-525-9416
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | L5896
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License Number State | OR
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