Provider Demographics
NPI:1104456524
Name:EDDY, WENDY (CADC1)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:EDDY
Suffix:
Gender:F
Credentials:CADC1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 MAITLAND CENTER PKWY STE 250
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-4174
Mailing Address - Country:US
Mailing Address - Phone:407-351-7080
Mailing Address - Fax:
Practice Address - Street 1:16420 SE DIVISION ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236-1987
Practice Address - Country:US
Practice Address - Phone:503-762-3130
Practice Address - Fax:503-762-3199
Is Sole Proprietor?:No
Enumeration Date:2020-01-24
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17-09-10101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)