Provider Demographics
NPI:1124409420
Name:GRADIN, SALLY K
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:K
Last Name:GRADIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13500 SW PACIFIC HWY STE 58-481
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-4804
Mailing Address - Country:US
Mailing Address - Phone:971-425-0821
Mailing Address - Fax:971-223-0968
Practice Address - Street 1:7340 SW HUNZIKER ST
Practice Address - Street 2:SUITE 102
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223
Practice Address - Country:US
Practice Address - Phone:971-425-0821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-11
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL102131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical