Provider Demographics
NPI:1205613361
Name:STURROCK, CAROLYN ELIZABETH
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:ELIZABETH
Last Name:STURROCK
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 1:2000 NE 42ND AVE # 1154
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-1399
Mailing Address - Country:US
Mailing Address - Phone:503-313-4616
Mailing Address - Fax:
Practice Address - Street 1:3024 NE 18TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-3356
Practice Address - Country:US
Practice Address - Phone:503-313-4616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-12
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health