Provider Demographics
NPI:1205305489
Name:CARBONNEAU, SARA LUCILLE (LAC)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:LUCILLE
Last Name:CARBONNEAU
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 NE SCHUYLER ST APT 3
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-4448
Mailing Address - Country:US
Mailing Address - Phone:301-639-6917
Mailing Address - Fax:
Practice Address - Street 1:1017 SW MORRISON ST STE 405
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2629
Practice Address - Country:US
Practice Address - Phone:301-639-6917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-18
Last Update Date:2018-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC190041171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty