Healthcare Provider Details

I. General information

NPI: 1285985101
Provider Name (Legal Business Name): SARAH E HLEBICHUK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2012
Last Update Date: 11/04/2022
Certification Date: 11/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 W COMMERCE DR STE F
HAYDEN ID
83835-9289
US

IV. Provider business mailing address

PO BOX 895
HAYDEN ID
83835-0895
US

V. Phone/Fax

Practice location:
  • Phone: 208-704-0046
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-35594
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-29995
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: