Provider Demographics
NPI:1083265706
Name:SKAALAND, SAMUEL
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:SKAALAND
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 SW CLAY ST APT 304
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-6008
Mailing Address - Country:US
Mailing Address - Phone:608-213-6956
Mailing Address - Fax:
Practice Address - Street 1:34651 SE KELSO RD
Practice Address - Street 2:
Practice Address - City:BORING
Practice Address - State:OR
Practice Address - Zip Code:97009-7041
Practice Address - Country:US
Practice Address - Phone:503-668-8020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-24
Last Update Date:2022-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO14297262235Z00000X
OR17185235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist