Healthcare Provider Details

I. General information

NPI: 1205430170
Provider Name (Legal Business Name): SANDRA LEE GLEASON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SANDRA LEE FERRELL PSS

II. Dates (important events)

Enumeration Date: 11/22/2020
Last Update Date: 11/22/2023
Certification Date: 11/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 W 4TH AVE
EUGENE OR
97402-5022
US

IV. Provider business mailing address

687 CHESHIRE AVE
EUGENE OR
97402-5060
US

V. Phone/Fax

Practice location:
  • Phone: 541-762-4575
  • Fax: 541-762-0728
Mailing address:
  • Phone: 541-684-4100
  • Fax: 541-684-4156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberTHW000004015
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: