Healthcare Provider Details

I. General information

NPI: 1669736096
Provider Name (Legal Business Name): ANGELICA MARIA SANCHEZ LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ANGELICA MARIA MARTINEZ LCSW, CADCI

II. Dates (important events)

Enumeration Date: 06/29/2012
Last Update Date: 12/13/2021
Certification Date: 12/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 NE BURNSIDE RD STE 401B
GRESHAM OR
97030-5705
US

IV. Provider business mailing address

1217 NE BURNSIDE RD STE 401B
GRESHAM OR
97030-5705
US

V. Phone/Fax

Practice location:
  • Phone: 503-714-6426
  • Fax:
Mailing address:
  • Phone: 503-714-6426
  • Fax: 503-912-7019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number13-12-25
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL6367
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier500671951
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: