Provider Demographics
NPI:1760577738
Name:BANDEEN, GINGER
Entity Type:Individual
Prefix:
First Name:GINGER
Middle Name:
Last Name:BANDEEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3587 HEATHROW WAY
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4004
Mailing Address - Country:US
Mailing Address - Phone:541-858-8170
Mailing Address - Fax:
Practice Address - Street 1:17720 NE HALSEY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-6734
Practice Address - Country:US
Practice Address - Phone:503-654-7654
Practice Address - Fax:503-654-7333
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL34251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
R159760Medicare PIN
OR123190Medicaid
OR131256Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER