Provider Demographics
NPI:1265857627
Name:SANDRA J. KRUSSEL, DO, PSYCHIATRIST, LLC
Entity type:Organization
Organization Name:SANDRA J. KRUSSEL, DO, PSYCHIATRIST, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:KRUSSEL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:503-226-0558
Mailing Address - Street 1:2250 NW FLANDERS ST
Mailing Address - Street 2:SUITE 306
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-3443
Mailing Address - Country:US
Mailing Address - Phone:503-226-0558
Mailing Address - Fax:503-276-1284
Practice Address - Street 1:2250 NW FLANDERS ST
Practice Address - Street 2:306
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3443
Practice Address - Country:US
Practice Address - Phone:503-226-0558
Practice Address - Fax:503-276-1284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-21
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO1526422084P0800X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty