Provider Demographics
NPI:1619032828
Name:BLACKWOOD, SALLY J (MA, LPC)
Entity type:Individual
Prefix:MS
First Name:SALLY
Middle Name:J
Last Name:BLACKWOOD
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3615 NE GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-2104
Mailing Address - Country:US
Mailing Address - Phone:503-789-5261
Mailing Address - Fax:
Practice Address - Street 1:4838 NE SANDY BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2091
Practice Address - Country:US
Practice Address - Phone:503-789-5261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC1163101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health