Provider Demographics
NPI:1528285392
Name:GRASS, SANDRA (LPC)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:GRASS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:
Other - Last Name:GRASS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:2525 NW LOVEJOY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-2859
Mailing Address - Country:US
Mailing Address - Phone:503-563-3420
Mailing Address - Fax:
Practice Address - Street 1:2525 NW LOVEJOY ST STE 310
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2864
Practice Address - Country:US
Practice Address - Phone:503-563-3420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC3759101YM0800X
WI3454-123101YM0800X
WI1524-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39629100Medicaid