Provider Demographics
NPI:1194285411
Name:SOONDAROTOK, ONAMPAI MODI (LCSW)
Entity type:Individual
Prefix:
First Name:ONAMPAI MODI
Middle Name:
Last Name:SOONDAROTOK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 NE 42ND AVE # 1004
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-1399
Mailing Address - Country:US
Mailing Address - Phone:503-683-1558
Mailing Address - Fax:
Practice Address - Street 1:2000 NE 42ND AVE # 1004
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-1399
Practice Address - Country:US
Practice Address - Phone:503-683-1558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-22
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ORL110711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program