Healthcare Provider Details

I. General information

NPI: 1033613815
Provider Name (Legal Business Name): NICK SUNDSTROM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2018
Last Update Date: 10/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2659 SW 4TH ST STE 110
REDMOND OR
97756
US

IV. Provider business mailing address

2659 SW 4TH ST STE 110
REDMOND OR
97756-6406
US

V. Phone/Fax

Practice location:
  • Phone: 541-647-7820
  • Fax:
Mailing address:
  • Phone: 541-647-7820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number4413
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number4413
License Number StateOR

VIII. Authorized Official

Name: NICHOLAS ERIC SUNDSTROM
Title or Position: OWNER/PROVIDER
Credential: LCSW
Phone: 541-647-7820