Provider Demographics
NPI:1265591010
Name:STREETER, MARY T
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:T
Last Name:STREETER
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 1:3577 HAWTHORNE AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-1917
Mailing Address - Country:US
Mailing Address - Phone:541-688-0460
Mailing Address - Fax:
Practice Address - Street 1:3577 HAWTHORNE AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97402-1917
Practice Address - Country:US
Practice Address - Phone:541-688-0460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2011-506306-0711-REL177F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes177F00000XOther Service ProvidersLodging
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR2011-506306-0711-RELOtherRELATIVE FOSTER CARE