Healthcare Provider Details

I. General information

NPI: 1962380790
Provider Name (Legal Business Name): KRYSTAL TODERICK M.ED
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2025
Last Update Date: 08/21/2025
Certification Date: 08/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5405 SE WOODWARD ST
PORTLAND OR
97206-2199
US

IV. Provider business mailing address

501 N DIXON ST
PORTLAND OR
97227-1876
US

V. Phone/Fax

Practice location:
  • Phone: 503-916-5140
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number512576
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: