Provider Demographics
NPI:1073686853
Name:WENDELBORG, SUSAN MARIE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:MARIE
Last Name:WENDELBORG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1863 PIONEER PKWY E
Mailing Address - Street 2:#441
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-3907
Mailing Address - Country:US
Mailing Address - Phone:773-213-1392
Mailing Address - Fax:541-722-7033
Practice Address - Street 1:131 E 11TH AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3511
Practice Address - Country:US
Practice Address - Phone:773-213-1392
Practice Address - Fax:541-722-7033
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0084351041C0700X
ORL58961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1627533OtherBCBS
IL662060Medicare ID - Type Unspecified