Provider Demographics
NPI:1033613815
Name:NICK SUNDSTROM LLC
Entity type:Organization
Organization Name:NICK SUNDSTROM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:SUNDSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:541-647-7820
Mailing Address - Street 1:2659 SW 4TH ST STE 110
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-6406
Mailing Address - Country:US
Mailing Address - Phone:541-647-7820
Mailing Address - Fax:
Practice Address - Street 1:2659 SW 4TH ST STE 110
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756
Practice Address - Country:US
Practice Address - Phone:541-647-7820
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-19
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4413251S00000X, 261QM0850X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health