Provider Demographics
NPI:1124342415
Name:STELLAVATO, SANDRA KAY (LCSW, LADC)
Entity type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:KAY
Last Name:STELLAVATO
Suffix:
Gender:F
Credentials:LCSW, LADC
Other - Prefix:MISS
Other - First Name:SANDRA
Other - Middle Name:KAY
Other - Last Name:SUTTON (MAIDEN)
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:975 POLK ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-4537
Mailing Address - Country:US
Mailing Address - Phone:541-357-4182
Mailing Address - Fax:
Practice Address - Street 1:2411 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-5824
Practice Address - Country:US
Practice Address - Phone:541-682-7551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-16
Last Update Date:2010-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV00520-L101YA0400X
ORL45741041C0700X
NV2780-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)