Provider Demographics
NPI:1780317966
Name:ANANDAVALLI, S (PHD, LPCA, NCC, CCTP)
Entity type:Individual
Prefix:
First Name:S
Middle Name:
Last Name:ANANDAVALLI
Suffix:
Gender:F
Credentials:PHD, LPCA, NCC, CCTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4698 NE BEAUMEAD LN
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-6664
Mailing Address - Country:US
Mailing Address - Phone:620-238-2984
Mailing Address - Fax:
Practice Address - Street 1:1133 NW WALL ST STE 1
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-1976
Practice Address - Country:US
Practice Address - Phone:971-202-1927
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-06
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR6591101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty