Healthcare Provider Details

I. General information

NPI: 1265857627
Provider Name (Legal Business Name): SANDRA J. KRUSSEL, DO, PSYCHIATRIST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2014
Last Update Date: 02/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2250 NW FLANDERS ST 306
PORTLAND OR
97210-3443
US

IV. Provider business mailing address

2250 NW FLANDERS ST SUITE 306
PORTLAND OR
97210-3443
US

V. Phone/Fax

Practice location:
  • Phone: 503-226-0558
  • Fax: 503-276-1284
Mailing address:
  • Phone: 503-226-0558
  • Fax: 503-276-1284

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberDO152642
License Number StateOR

VIII. Authorized Official

Name: DR. SANDRA JANE KRUSSEL
Title or Position: SOLE MEMBER
Credential: DO
Phone: 503-226-0558