Provider Demographics
NPI:1184022493
Name:HERNANDEZ, SARAH (LCSW-36400)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:LCSW-36400
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:
Other - Last Name:HERNANDEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW-33381
Mailing Address - Street 1:1908 JENNIE LEE DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6159
Mailing Address - Country:US
Mailing Address - Phone:208-932-7048
Mailing Address - Fax:208-970-6188
Practice Address - Street 1:1908 JENNIE LEE DR
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6159
Practice Address - Country:US
Practice Address - Phone:208-932-7048
Practice Address - Fax:208-970-6188
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-18
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-33381261QM0850X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1184022493Medicaid