Basic Information
| Provider Information | |||||||||
| NPI: | 1831433812 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANDERS | ||||||||
| FirstName: | EZEKIEL | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3158 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032156494 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 384 SE COMBS FLAT RD STE 1200 | ||||||||
| Address2: | |||||||||
| City: | PRINEVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977542562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414476263 | ||||||||
| FaxNumber: | 5414478724 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2012 | ||||||||
| LastUpdateDate: | 04/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | OR | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103TC0700X | 3132 | OR | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.