Healthcare Provider Details

I. General information

NPI: 1750064010
Provider Name (Legal Business Name): KYLEA SKYE SUNDBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KYLEA SCHMIDT

II. Dates (important events)

Enumeration Date: 08/11/2023
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12636 SE STARK ST STE 125
PORTLAND OR
97233-1058
US

IV. Provider business mailing address

PO BOX 8459
PORTLAND OR
97207-8459
US

V. Phone/Fax

Practice location:
  • Phone: 503-238-0769
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberR11816
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: