Provider Demographics
NPI:1710487228
Name:LACKNER, SARAH
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:LACKNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43350 E BILYEU CREEK DR
Mailing Address - Street 2:
Mailing Address - City:SCIO
Mailing Address - State:OR
Mailing Address - Zip Code:97374-9335
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1050 29TH AVE SW
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-3416
Practice Address - Country:US
Practice Address - Phone:541-926-4828
Practice Address - Fax:541-926-4891
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-20
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0801X
OR104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORM7386OtherOBLSW