Provider Demographics
NPI:1760861876
Name:GAUDERMAN, KAISHA
Entity Type:Individual
Prefix:
First Name:KAISHA
Middle Name:
Last Name:GAUDERMAN
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 1:71 CENTENNIAL LOOP STE A
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2443
Practice Address - Country:US
Practice Address - Phone:541-505-8426
Practice Address - Fax:541-515-6938
Is Sole Proprietor?:No
Enumeration Date:2015-05-21
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health