Provider Demographics
NPI:1871675108
Name:MUSSACK, STEVEN E I (PHD)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:E
Last Name:MUSSACK
Suffix:I
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1973 GARDEN AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97403-1934
Mailing Address - Country:US
Mailing Address - Phone:541-343-7643
Mailing Address - Fax:541-344-5255
Practice Address - Street 1:1973 GARDEN AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97403-1934
Practice Address - Country:US
Practice Address - Phone:541-343-7643
Practice Address - Fax:541-344-5255
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR822103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR087239Medicaid
OR0000TCHSZMedicare ID - Type Unspecified