Healthcare Provider Details

I. General information

NPI: 1942574413
Provider Name (Legal Business Name): VIRGINIA LOUISE SACKETT LCSW, ED.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2012
Last Update Date: 09/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 SHELTON MCMURPHEY BLVD STE 101
EUGENE OR
97401-5015
US

IV. Provider business mailing address

150 SHELTON MCMURPHEY BLVD STE 101
EUGENE OR
97401-5015
US

V. Phone/Fax

Practice location:
  • Phone: 541-210-8090
  • Fax:
Mailing address:
  • Phone: 541-210-8090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL6581
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier500668331
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: