Healthcare Provider Details

I. General information

NPI: 1356780027
Provider Name (Legal Business Name): SARAH MICHELLE LUDOVIC LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SARAH MICHELLE YOUNG

II. Dates (important events)

Enumeration Date: 06/17/2013
Last Update Date: 06/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 16TH AVE N
NAMPA ID
83687-4058
US

IV. Provider business mailing address

211 16TH AVE N PO BOX 9
NAMPA ID
83687-4058
US

V. Phone/Fax

Practice location:
  • Phone: 208-467-7654
  • Fax:
Mailing address:
  • Phone: 208-461-7149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-33046
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: