Provider Demographics
NPI:1629566583
Name:KIESON, SADIE PAMELA (LMSW)
Entity Type:Individual
Prefix:
First Name:SADIE
Middle Name:PAMELA
Last Name:KIESON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-5658
Mailing Address - Country:US
Mailing Address - Phone:701-444-3661
Mailing Address - Fax:701-444-6436
Practice Address - Street 1:222 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-5658
Practice Address - Country:US
Practice Address - Phone:701-421-7640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-26
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND63311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1460241Medicaid