Provider Demographics
NPI:1639536691
Name:SHADBOLT, ERNST UDEY (CADC I)
Entity Type:Individual
Prefix:
First Name:ERNST
Middle Name:UDEY
Last Name:SHADBOLT
Suffix:
Gender:M
Credentials:CADC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1121
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-0254
Mailing Address - Country:US
Mailing Address - Phone:541-673-5119
Mailing Address - Fax:541-957-3734
Practice Address - Street 1:2064 SE DOUGLAS AVE
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-3713
Practice Address - Country:US
Practice Address - Phone:541-673-5119
Practice Address - Fax:541-957-3734
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-21
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR08-03-32101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)