Provider Demographics
NPI:1841469616
Name:SANDERSON, TARA (PSYD, MBA)
Entity type:Individual
Prefix:DR
First Name:TARA
Middle Name:
Last Name:SANDERSON
Suffix:
Gender:F
Credentials:PSYD, MBA
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:CULALA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:901 BRUTSCHER ST # D141
Mailing Address - Street 2:
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132-6096
Mailing Address - Country:US
Mailing Address - Phone:971-264-0879
Mailing Address - Fax:971-925-8613
Practice Address - Street 1:11845 SW GREENBURG RD STE 210
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-6464
Practice Address - Country:US
Practice Address - Phone:971-264-0879
Practice Address - Fax:971-266-4521
Is Sole Proprietor?:No
Enumeration Date:2008-02-26
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2324103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500706752OtherDMAP