Provider Demographics
NPI:1689604290
Name:CONDON, STEPHEN R (PHD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:R
Last Name:CONDON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 SE COURT AVE
Mailing Address - Street 2:STE 4
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801-2251
Mailing Address - Country:US
Mailing Address - Phone:541-278-4123
Mailing Address - Fax:541-278-4123
Practice Address - Street 1:125 SE COURT AVE
Practice Address - Street 2:STE 4
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97801-2251
Practice Address - Country:US
Practice Address - Phone:541-278-4123
Practice Address - Fax:541-278-4123
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR570103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR808119000OtherREGENCE BLUE CROSS BLUE S
OR010673Medicaid