Provider Demographics
NPI:1841976479
Name:PREVO, EMILY ALEXANDRIA
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:ALEXANDRIA
Last Name:PREVO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:ALEXANDRIA
Other - Last Name:PREVO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3425 13TH ST
Mailing Address - Street 2:
Mailing Address - City:BAKER CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97814-1340
Mailing Address - Country:US
Mailing Address - Phone:541-523-7400
Mailing Address - Fax:541-523-4927
Practice Address - Street 1:3700 MIDWAY DR
Practice Address - Street 2:
Practice Address - City:BAKER CITY
Practice Address - State:OR
Practice Address - Zip Code:97814-1456
Practice Address - Country:US
Practice Address - Phone:541-523-8320
Practice Address - Fax:541-523-8325
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-27
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT-23-2789101YA0400X
ORPENDING101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORB093405OtherODL