Basic Information
| Provider Information | |||||||||
| NPI: | 1114432382 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOBDEL | ||||||||
| FirstName: | WENDY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PSS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3091 ELMIRA RD | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974022387 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418016552 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2145 CENTENNIAL PLZ | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974012421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414856340 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2017 | ||||||||
| LastUpdateDate: | 12/08/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | THW2341 | OR | Y |
ID Information
| ID | Type | State | Issuer | Description | THW2341 | 05 | OR | MEDICAID |