Basic Information
| Provider Information | |||||||||
| NPI: | 1669724316 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GIUDICE | ||||||||
| FirstName: | EVAN | ||||||||
| MiddleName: | ANGELO | ||||||||
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| Credential: | LMFT, CADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2577 NE COURTNEY DR | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977017638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413227500 | ||||||||
| FaxNumber: | 5413227565 | ||||||||
| Practice Location | |||||||||
| Address1: | 406 W ANTLER AVE | ||||||||
| Address2: | |||||||||
| City: | REDMOND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977561812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413227414 | ||||||||
| FaxNumber: | 5413162268 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2012 | ||||||||
| LastUpdateDate: | 10/16/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 69067 | CA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YA0400X | OR | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 106H00000X | T0982 | OR | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.