Provider Demographics
NPI:1083971063
Name:CHAN, SARA S (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SARA
Middle Name:S
Last Name:CHAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:1600 E JEFFERSON ST STE A1
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-5643
Practice Address - Country:US
Practice Address - Phone:206-320-2200
Practice Address - Fax:206-320-2560
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-16
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY61196914103TC0700X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2212898Medicaid