Provider Demographics
NPI:1033668454
Name:TENGREN, ERIC
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:TENGREN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3587 HEATHROW WAY
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4004
Mailing Address - Country:US
Mailing Address - Phone:480-432-5551
Mailing Address - Fax:
Practice Address - Street 1:29413 RUSSELL ST
Practice Address - Street 2:
Practice Address - City:GOLD BEACH
Practice Address - State:OR
Practice Address - Zip Code:97444
Practice Address - Country:US
Practice Address - Phone:541-247-6566
Practice Address - Fax:541-247-6549
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-27
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NM171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health