Provider Demographics
NPI:1407298268
Name:THEDFORD, ANNA DANAE (MA, LPC, LSC)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:DANAE
Last Name:THEDFORD
Suffix:
Gender:F
Credentials:MA, LPC, LSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62930 O B RILEY RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-9458
Mailing Address - Country:US
Mailing Address - Phone:541-390-8655
Mailing Address - Fax:888-802-5120
Practice Address - Street 1:62930 O B RILEY RD
Practice Address - Street 2:SUITE 300
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-9458
Practice Address - Country:US
Practice Address - Phone:541-390-8655
Practice Address - Fax:888-802-5120
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-22
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR283234Medicaid