Healthcare Provider Details

I. General information

NPI: 1316334527
Provider Name (Legal Business Name): SANDRA MACKERELL QMHP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2015
Last Update Date: 06/09/2020
Certification Date: 06/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

398 HIGH ST
EUGENE OR
97401-2310
US

IV. Provider business mailing address

4080 REED RD SE STE 150
SALEM OR
97302-1335
US

V. Phone/Fax

Practice location:
  • Phone: 541-344-1121
  • Fax: 541-344-4780
Mailing address:
  • Phone: 503-581-1732
  • Fax: 541-686-0359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC5627
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC5627
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: