Provider Demographics
NPI:1245791037
Name:SMIDSTRA, SARAH (LAC)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:SMIDSTRA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:
Other - Last Name:HUTCHISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:690 E WARNER RD
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-3054
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:690 E WARNER RD
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-3054
Practice Address - Country:US
Practice Address - Phone:480-444-2434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-16716101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor