Healthcare Provider Details

I. General information

NPI: 1245406016
Provider Name (Legal Business Name): SARAH RANDOLPH HIXSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SARAH R HIXSON LCSW

II. Dates (important events)

Enumeration Date: 05/01/2008
Last Update Date: 12/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 COUNTRY CLUB LANE
PINEDALE WY
82941
US

IV. Provider business mailing address

PO BOX 856
PINEDALE WY
82941-0856
US

V. Phone/Fax

Practice location:
  • Phone: 307-367-2111
  • Fax: 307-367-2166
Mailing address:
  • Phone: 307-367-2111
  • Fax: 307-367-2166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLCSW 276
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: