Provider Demographics
NPI:1972937829
Name:VAN DUSEN, TERAH
Entity Type:Individual
Prefix:
First Name:TERAH
Middle Name:
Last Name:VAN DUSEN
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:PO BOX 461
Mailing Address - Street 2:
Mailing Address - City:NOTI
Mailing Address - State:OR
Mailing Address - Zip Code:97461-0461
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:590 TYLER ST
Practice Address - Street 2:#3
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97402-4552
Practice Address - Country:US
Practice Address - Phone:323-829-1748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-28
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor