Provider Demographics
NPI:1861258386
Name:DURAM, SANDRA LYNN (CADC 1)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:LYNN
Last Name:DURAM
Suffix:
Gender:F
Credentials:CADC 1
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:LYNN
Other - Last Name:KNOWLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3100 SE 168TH AVE APT 134
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-2112
Mailing Address - Country:US
Mailing Address - Phone:616-375-2428
Mailing Address - Fax:
Practice Address - Street 1:6025 SE BELMONT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-1927
Practice Address - Country:US
Practice Address - Phone:866-262-0531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-22
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23-R-52101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)