Basic Information
| Provider Information | |||||||||
| NPI: | 1780712851 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EMERGENCE ADDICTION AND BEHAVIORAL THERAPIES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ADDICTION COUNSELING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7125 | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974010006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413930777 | ||||||||
| FaxNumber: | 5417365015 | ||||||||
| Practice Location | |||||||||
| Address1: | 2149 CENTENNIAL PLZ | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974012456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413930777 | ||||||||
| FaxNumber: | 5417365015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | OYLER | ||||||||
| AuthorizedOfficialFirstName: | DON | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | INSURANCE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5413930777 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | OR | X | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | OR | X | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 133426 | 05 | OR | MEDICAID |