Provider Demographics
NPI:1568675361
Name:KIVISTO, SARAH (LISW)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:KIVISTO
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24666 257TH ST
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:IA
Mailing Address - Zip Code:52768-9727
Mailing Address - Country:US
Mailing Address - Phone:563-265-0825
Mailing Address - Fax:
Practice Address - Street 1:2550 MIDDLE RD
Practice Address - Street 2:STE 3
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-3298
Practice Address - Country:US
Practice Address - Phone:563-888-6275
Practice Address - Fax:563-884-4638
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA065491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
420716337OtherEIN
07452013Medicare PIN