Provider Demographics
NPI:1043532252
Name:GUBBELS, SARAH J (LICSW)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:J
Last Name:GUBBELS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 MAIN AVE S
Mailing Address - Street 2:
Mailing Address - City:BAUDETTE
Mailing Address - State:MN
Mailing Address - Zip Code:56623-2855
Mailing Address - Country:US
Mailing Address - Phone:218-634-1655
Mailing Address - Fax:218-634-1094
Practice Address - Street 1:600 MAIN AVE S
Practice Address - Street 2:
Practice Address - City:BAUDETTE
Practice Address - State:MN
Practice Address - Zip Code:56623-2855
Practice Address - Country:US
Practice Address - Phone:218-634-2120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-16
Last Update Date:2021-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4252104100000X, 1041C0700X
MTSWP-LCSW-LIC-46441041C0700X
MN300721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND19308Medicaid
ND1043532252OtherBLUE CROSS/BLUE SHIELD OF ND
ND74133Medicaid