Basic Information
| Provider Information | |||||||||
| NPI: | 1669508412 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUNDSTROM CLINICAL SERVICES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21900 WILLAMETTE DR STE 202 | ||||||||
| Address2: | |||||||||
| City: | WEST LINN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970683284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036530631 | ||||||||
| FaxNumber: | 5036531464 | ||||||||
| Practice Location | |||||||||
| Address1: | 21900 WILLAMETTE DR STE 202 | ||||||||
| Address2: | |||||||||
| City: | WEST LINN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970683284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036530631 | ||||||||
| FaxNumber: | 5036531464 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2007 | ||||||||
| LastUpdateDate: | 01/30/2018 | ||||||||
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| AuthorizedOfficialLastName: | LAZRINE | ||||||||
| AuthorizedOfficialFirstName: | CAROL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5036530631 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 01229457-2 | OR | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.