Provider Demographics
NPI:1285820704
Name:RUSTAM, SANDRA (MA, LPCI)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:RUSTAM
Suffix:
Gender:F
Credentials:MA, LPCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14745 SW SANDHILL LOOP
Mailing Address - Street 2:SUITE 204
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97007-9079
Mailing Address - Country:US
Mailing Address - Phone:503-730-1790
Mailing Address - Fax:
Practice Address - Street 1:3601 SW MURRAY BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-2354
Practice Address - Country:US
Practice Address - Phone:503-730-1790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-18
Last Update Date:2016-11-25
Deactivation Date:2013-07-29
Deactivation Code:
Reactivation Date:2016-11-17
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No251S00000XAgenciesCommunity/Behavioral Health
No302R00000XManaged Care OrganizationsHealth Maintenance Organization
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No101Y00000XBehavioral Health & Social Service ProvidersCounselor