Provider Demographics
NPI:1811903263
Name:SHULMIRE, SANDRA L (PSYD)
Entity type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:L
Last Name:SHULMIRE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13831 NW CORNELL RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-5485
Mailing Address - Country:US
Mailing Address - Phone:503-645-2944
Mailing Address - Fax:503-645-2944
Practice Address - Street 1:13831 NW CORNELL RD
Practice Address - Street 2:SUITE 101
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-5485
Practice Address - Country:US
Practice Address - Phone:503-645-2944
Practice Address - Fax:503-645-2944
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR#1186103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR077730Medicaid
OR021753OtherMHN PIN#
OR480038OtherVALUE OPTIONS MHS#
OR077730Medicaid