Provider Demographics
NPI:1922317296
Name:EUBANK, ERIC LANE
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:LANE
Last Name:EUBANK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:LANE
Other - Middle Name:
Other - Last Name:EUBANK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3205 SE 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-2461
Mailing Address - Country:US
Mailing Address - Phone:503-258-4636
Mailing Address - Fax:503-254-6234
Practice Address - Street 1:3205 SE 13TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-2461
Practice Address - Country:US
Practice Address - Phone:503-258-4636
Practice Address - Fax:503-254-6234
Is Sole Proprietor?:No
Enumeration Date:2010-10-04
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health