Provider Demographics
NPI:1538449673
Name:SRODULSKI, ANN ELIZABETH (MA)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:ELIZABETH
Last Name:SRODULSKI
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9479 SW MAPLEWOOD DR
Mailing Address - Street 2:B14
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-4966
Mailing Address - Country:US
Mailing Address - Phone:847-502-7607
Mailing Address - Fax:
Practice Address - Street 1:1500 NE IRVING ST
Practice Address - Street 2:SUITE 250
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-2243
Practice Address - Country:US
Practice Address - Phone:503-258-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-21
Last Update Date:2011-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent