Healthcare Provider Details

I. General information

NPI: 1063668127
Provider Name (Legal Business Name): SANDIE LOUISE MCCRACKEN CADC II, AAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SANDIE LOUISE NELSON

II. Dates (important events)

Enumeration Date: 08/08/2008
Last Update Date: 03/22/2023
Certification Date: 03/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 5TH ST # 300
BROOKINGS OR
97415-9199
US

IV. Provider business mailing address

PO BOX 1121
ROSEBURG OR
97470-0254
US

V. Phone/Fax

Practice location:
  • Phone: 877-408-8941
  • Fax:
Mailing address:
  • Phone: 541-672-2691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: