Basic Information
| Provider Information | |||||||||
| NPI: | 1467709907 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUNDSTROM | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7515 FALCON CREST DR, SUITE 200 | ||||||||
| Address2: | |||||||||
| City: | REDMOND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977565014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419035822 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2542 NE COURTNEY DR | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977017685 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417062768 | ||||||||
| FaxNumber: | 5417064760 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2012 | ||||||||
| LastUpdateDate: | 07/29/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | L4413 | OR | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.