Provider Demographics
NPI:1669508412
Name:SUNDSTROM CLINICAL SERVICES LLC
Entity Type:Organization
Organization Name:SUNDSTROM CLINICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:LAZRINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-653-0631
Mailing Address - Street 1:21900 WILLAMETTE DR STE 202
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-3284
Mailing Address - Country:US
Mailing Address - Phone:503-653-0631
Mailing Address - Fax:503-653-1464
Practice Address - Street 1:21900 WILLAMETTE DR STE 202
Practice Address - Street 2:
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068-3284
Practice Address - Country:US
Practice Address - Phone:503-653-0631
Practice Address - Fax:503-653-1464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR01229457-2103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR848244000OtherREGENCE BCBS
OR848244000OtherREGENCE BCBS