Provider Demographics
NPI:1740847177
Name:ECCLES, STEPHEN JACK
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:JACK
Last Name:ECCLES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:TRILLIUM CHILDREN'S FARM HOME
Mailing Address - Street 2:4455 NE HWY 20
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330
Mailing Address - Country:US
Mailing Address - Phone:541-757-1852
Mailing Address - Fax:
Practice Address - Street 1:TRILLIUM CHILDREN'S FARM HOME
Practice Address - Street 2:4455 NE HWY 20
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330
Practice Address - Country:US
Practice Address - Phone:541-757-1852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-21
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician