1558643635 NPI number — MRS. KAREN JO STARK-BREDEWEG L.C.S.W

Table of content: MRS. KAREN JO STARK-BREDEWEG L.C.S.W (NPI 1558643635)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558643635 NPI number — MRS. KAREN JO STARK-BREDEWEG L.C.S.W

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STARK-BREDEWEG
Provider First Name:
KAREN
Provider Middle Name:
JO
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
L.C.S.W
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
STARK-BREDEWEG
Provider Other First Name:
KARIN
Provider Other Middle Name:
JO
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1558643635
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
921 COUNTRY CLUB RD
Provider Second Line Business Mailing Address:
SUITE #222
Provider Business Mailing Address City Name:
EUGENE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97401-2257
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-686-6000
Provider Business Mailing Address Fax Number:
541-433-8239

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
921 COUNTRY CLUB RD
Provider Second Line Business Practice Location Address:
SUITE #222
Provider Business Practice Location Address City Name:
EUGENE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97401-2257
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-686-6000
Provider Business Practice Location Address Fax Number:
541-433-8239
Provider Enumeration Date:
09/14/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  L3198 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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