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General NPI Number Information
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NPI Number | 1033613815
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Entity Type | Organization
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Legal Business Name | NICK SUNDSTROM LLC
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Dates
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Enumeration Date | 03/19/2018
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Last Update Date | 10/05/2018
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Provider Practice Location Address
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Address Line | 2659 SW 4TH ST STE 110
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City | REDMOND
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State | OR
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Zip | 97756
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Country | US
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Telephone | 541-647-7820
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Fax |
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Provider Business Mailing Address
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Address Line | 2659 SW 4TH ST STE 110
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City | REDMOND
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State | OR
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Zip | 97756-6406
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Country | US
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Telephone | 541-647-7820
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Fax |
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Authorized Official
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Title or Position | OWNER/PROVIDER
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Name | NICHOLAS ERIC SUNDSTROM
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Credential | LCSW
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Telephone | 541-647-7820
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 4413
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number | 4413
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License Number State | OR
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Taxonomy #3
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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