Provider Demographics
NPI:1316334527
Name:MACKERELL, SANDRA (QMHP)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:MACKERELL
Suffix:
Gender:F
Credentials:QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4080 REED RD SE STE 150
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-1335
Mailing Address - Country:US
Mailing Address - Phone:503-581-1732
Mailing Address - Fax:541-686-0359
Practice Address - Street 1:398 HIGH ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2310
Practice Address - Country:US
Practice Address - Phone:541-344-1121
Practice Address - Fax:541-344-4780
Is Sole Proprietor?:No
Enumeration Date:2015-04-26
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC5627101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health