Basic Information
| Provider Information | |||||||||
| NPI: | 1376070722 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUBELL | ||||||||
| FirstName: | MARTINA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 687 CHESHIRE AVE | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974025060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416844100 | ||||||||
| FaxNumber: | 5416844156 | ||||||||
| Practice Location | |||||||||
| Address1: | 1651 CENTENNIAL BLVD | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974773363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417624527 | ||||||||
| FaxNumber: | 5416844156 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2017 | ||||||||
| LastUpdateDate: | 10/24/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | OR | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 500725431 | 05 | OR | MEDICAID |