1366819849 NPI number — SANDRA J SPOONER MSW, CSWA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366819849 NPI number — SANDRA J SPOONER MSW, CSWA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPOONER
Provider First Name:
SANDRA
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW, CSWA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CARTER
Provider Other First Name:
SANDRA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSW, CSWA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1366819849
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/14/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12901 SE 97TH AVE
Provider Second Line Business Mailing Address:
SUITE 340
Provider Business Mailing Address City Name:
CLACKAMAS
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97015-7901
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-680-4551
Provider Business Mailing Address Fax Number:
503-655-6806

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12901 SE 97TH AVE
Provider Second Line Business Practice Location Address:
SUITE 340
Provider Business Practice Location Address City Name:
CLACKAMAS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97015-7901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-680-4551
Provider Business Practice Location Address Fax Number:
503-655-6806
Provider Enumeration Date:
08/31/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  A4462 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: SC60593676 . This is a "WASHINGTON STATE DEPARTMENT OF HEALTH" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: A4462 . This is a "CERTIFICATE OF CLINICAL SOCIAL WORK ASSOCIATE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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