Healthcare Provider Details

I. General information

NPI: 1831433812
Provider Name (Legal Business Name): EZEKIEL N SANDERS PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 02/08/2024
Certification Date: 02/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

384 SE COMBS FLAT RD STE 1200
PRINEVILLE OR
97754-2562
US

IV. Provider business mailing address

384 SE COMBS FLAT RD
PRINEVILLE OR
97754-2562
US

V. Phone/Fax

Practice location:
  • Phone: 541-447-6263
  • Fax: 541-447-8724
Mailing address:
  • Phone: 541-447-6263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3132
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: