Healthcare Provider Details

I. General information

NPI: 1770058851
Provider Name (Legal Business Name): KENNETH EUGENE SANDIN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2018
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4736 ROYAL AVE # 254
EUGENE OR
97402-1755
US

IV. Provider business mailing address

4736 ROYAL AVE # 254
EUGENE OR
97402-1755
US

V. Phone/Fax

Practice location:
  • Phone: 707-502-2833
  • Fax:
Mailing address:
  • Phone: 707-502-2833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL14016
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW108992
License Number StateCA

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: