Provider Demographics
NPI:1194192302
Name:SANDERSON, ISABELLE RAYA
Entity type:Individual
Prefix:
First Name:ISABELLE
Middle Name:RAYA
Last Name:SANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:722 NE 162ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-5760
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:722 NE 162ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-5760
Practice Address - Country:US
Practice Address - Phone:503-341-4798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-24
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
NY025454103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker