Provider Demographics
NPI:1285761585
Name:TADDESSE, SANDRA E (LAC)
Entity type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:E
Last Name:TADDESSE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 16402
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97292
Mailing Address - Country:US
Mailing Address - Phone:503-232-2500
Mailing Address - Fax:503-232-2700
Practice Address - Street 1:506 NE 49TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97292
Practice Address - Country:US
Practice Address - Phone:503-232-2500
Practice Address - Fax:503-232-2700
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC00663171100000X
OR7049225700000X
WAAC00002271171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist