Healthcare Provider Details

I. General information

NPI: 1063502136
Provider Name (Legal Business Name): SANDRA SOLOMON MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

291 W 12TH AVE
EUGENE OR
97401-3409
US

IV. Provider business mailing address

291 W 12TH AVE
EUGENE OR
97401-3409
US

V. Phone/Fax

Practice location:
  • Phone: 541-485-7039
  • Fax: 541-338-9365
Mailing address:
  • Phone: 541-485-7039
  • Fax: 541-338-9365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0136
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier115743
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerMENTAL HEALTH NETWORK
# 2
IdentifierJ917601
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerPACIFICSOURCE INSURANCE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: