Provider Demographics
NPI:1477125896
Name:SUNG, LUNA
Entity type:Individual
Prefix:
First Name:LUNA
Middle Name:
Last Name:SUNG
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 1:3550 N INTERSTATE AVE STE 490
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1196
Mailing Address - Country:US
Mailing Address - Phone:503-249-3434
Mailing Address - Fax:
Practice Address - Street 1:3550 N INTERSTATE AVE STE 490
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1196
Practice Address - Country:US
Practice Address - Phone:503-249-3434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-14
Last Update Date:2024-06-27
Deactivation Date:2023-10-11
Deactivation Code:
Reactivation Date:2024-06-24
Provider Licenses
StateLicense IDTaxonomies
ORC5530101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health