Basic Information
| Provider Information | |||||||||
| NPI: | 1376693721 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ECKSTEIN | ||||||||
| FirstName: | JUDITH | ||||||||
| MiddleName: | KAREN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1652 NW HUGHWOOD CT | ||||||||
| Address2: | |||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974718844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416733985 | ||||||||
| FaxNumber: | 5416738060 | ||||||||
| Practice Location | |||||||||
| Address1: | 1652 NW HUGHWOOD CT | ||||||||
| Address2: | |||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974718844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416733985 | ||||||||
| FaxNumber: | 5416738060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2007 | ||||||||
| LastUpdateDate: | 03/28/2016 | ||||||||
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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 | 103TC0700X | C0710 | OR | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 816113003 | 01 | OR | REGENCE BLUE CROSS BLUE SHIELD | OTHER | 148817 | 05 | OR | MEDICAID |