Provider Demographics
NPI:1508292061
Name:DEJANAKUL-WOLFE, CHARVEY MARIE (BED)
Entity Type:Individual
Prefix:MRS
First Name:CHARVEY
Middle Name:MARIE
Last Name:DEJANAKUL-WOLFE
Suffix:
Gender:F
Credentials:BED
Other - Prefix:MISS
Other - First Name:CHARVEY
Other - Middle Name:MARIE
Other - Last Name:DEJANAKUL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BED
Mailing Address - Street 1:78 CENTENNIAL LOOP STE A
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-7900
Mailing Address - Country:US
Mailing Address - Phone:541-350-2101
Mailing Address - Fax:
Practice Address - Street 1:78 CENTENNIAL LOOP STE A
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-7900
Practice Address - Country:US
Practice Address - Phone:458-205-7631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-16
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)