Provider Demographics
NPI:1336772417
Name:KOYANO, SARA A (QMHP-R, CADC-R)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:A
Last Name:KOYANO
Suffix:
Gender:F
Credentials:QMHP-R, CADC-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1121
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-0254
Mailing Address - Country:US
Mailing Address - Phone:541-492-4550
Mailing Address - Fax:
Practice Address - Street 1:3099 NE DIAMOND LAKE BLVD
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-3655
Practice Address - Country:US
Practice Address - Phone:541-673-3469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-18
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT-21-1068101YA0400X
OR20-QMHP-R-0193101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500776784Medicaid