Provider Demographics
NPI:1104224393
Name:VON COLDITZ, SARAH (LCSW)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:VON COLDITZ
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 1:10 PIER 1
Mailing Address - Street 2:STE 204
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-6328
Mailing Address - Country:US
Mailing Address - Phone:503-789-6850
Mailing Address - Fax:
Practice Address - Street 1:10 PIER 1
Practice Address - Street 2:STE 204
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-6328
Practice Address - Country:US
Practice Address - Phone:503-789-6850
Practice Address - Fax:888-971-4017
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-20
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6292101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health