Healthcare Provider Details

I. General information

NPI: 1003691114
Provider Name (Legal Business Name): SAMMY TRAVIS FRESHNER JR. M.ED, MAC, LPCRA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2023
Last Update Date: 08/28/2023
Certification Date: 08/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1584 NE 8TH ST STE 200
GRESHAM OR
97030-5746
US

IV. Provider business mailing address

3650 NE ALTON CT
FAIRVIEW OR
97024-7736
US

V. Phone/Fax

Practice location:
  • Phone: 503-890-8773
  • Fax:
Mailing address:
  • Phone: 503-209-3995
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberR5274
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: