Provider Demographics
NPI:1164607248
Name:GRINNELL, SARAH FISHER (EDS)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:FISHER
Last Name:GRINNELL
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4696 W OVERLAND RD STE 232
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-2864
Mailing Address - Country:US
Mailing Address - Phone:208-471-4969
Mailing Address - Fax:
Practice Address - Street 1:4696 W OVERLAND RD STE 232
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-2864
Practice Address - Country:US
Practice Address - Phone:208-471-4969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-08
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-8942101YP2500X
AZ3527748103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional