Basic Information
Provider Information | |||||||||
NPI: | 1912491366 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DRAZDOWSKI | ||||||||
FirstName: | TESS | ||||||||
MiddleName: | KOVACS | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PH.D., QMHP, CADCC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DRAZDOWSKI | ||||||||
OtherFirstName: | TESS | ||||||||
OtherMiddleName: | KATHERINE | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 10 SHELTON MCMURPHEY BLVD | ||||||||
Address2: |   | ||||||||
City: | EUGENE | ||||||||
State: | OR | ||||||||
PostalCode: | 974014928 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5414852711 | ||||||||
FaxNumber: | 8889750250 | ||||||||
Practice Location | |||||||||
Address1: | 10 SHELTON MCMURPHEY BLVD | ||||||||
Address2: |   | ||||||||
City: | EUGENE | ||||||||
State: | OR | ||||||||
PostalCode: | 974014928 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5414852711 | ||||||||
FaxNumber: | 8889750250 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/19/2018 | ||||||||
LastUpdateDate: | 08/19/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/19/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X |   |   | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YA0400X | T-18-295 | OR | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 103T00000X | 31103 | CA | N |   | Behavioral Health & Social Service Providers | Psychologist |   | 103T00000X | 3243 | OR | Y |   | Behavioral Health & Social Service Providers | Psychologist |   |
ID Information
ID | Type | State | Issuer | Description | 500764726 | 05 | OR |   | MEDICAID | 500747734 | 05 | OR |   | MEDICAID |