Provider Demographics
NPI:1205592516
Name:HEATHER FUDGE LLC
Entity type:Organization
Organization Name:HEATHER FUDGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:FUDGE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:360-870-3944
Mailing Address - Street 1:PO BOX 11103
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97440-3303
Mailing Address - Country:US
Mailing Address - Phone:360-870-3394
Mailing Address - Fax:
Practice Address - Street 1:438 CHARNELTON ST STE 101
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2760
Practice Address - Country:US
Practice Address - Phone:360-870-3394
Practice Address - Fax:541-543-2525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-10
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500660658Medicaid