Provider Demographics
NPI:1003691114
Name:FRESHNER, SAMMY TRAVIS JR (MED, MAC, LPCRA)
Entity Type:Individual
Prefix:MR
First Name:SAMMY
Middle Name:TRAVIS
Last Name:FRESHNER
Suffix:JR
Gender:M
Credentials:MED, MAC, LPCRA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3650 NE ALTON CT
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97024-7736
Mailing Address - Country:US
Mailing Address - Phone:503-209-3995
Mailing Address - Fax:
Practice Address - Street 1:1584 NE 8TH ST STE 200
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-5746
Practice Address - Country:US
Practice Address - Phone:503-890-8773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR5274101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health