Provider Demographics
NPI:1770623928
Name:SUNDSTROM, PAUL (EDD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:SUNDSTROM
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8440 SE SUNNYBROOK BLVD
Mailing Address - Street 2:STE 120
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-5780
Mailing Address - Country:US
Mailing Address - Phone:503-653-0631
Mailing Address - Fax:
Practice Address - Street 1:8440 SE SUNNYBROOK BLVD
Practice Address - Street 2:STE 120
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-5780
Practice Address - Country:US
Practice Address - Phone:503-653-0631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR607103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR121465Medicare ID - Type Unspecified