Basic Information
| Provider Information | |||||||||
| NPI: | 1003029000 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALTERS | ||||||||
| FirstName: | SABRINA | ||||||||
| MiddleName: | JEN | ||||||||
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| Credential: | LPC, LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16849 NW PAISLEY DR | ||||||||
| Address2: | |||||||||
| City: | BEAVERTON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970064704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034390364 | ||||||||
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| Practice Location | |||||||||
| Address1: | 21210 NW MAUZEY RD | ||||||||
| Address2: | |||||||||
| City: | HILLSBORO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034399531 | ||||||||
| FaxNumber: | 5035313841 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | C1890 | OR | X | Behavioral Health & Social Service Providers | Counselor | Professional | 106H00000X | T0546 | OR | X | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 164936 | 05 | OR | MEDICAID |