Provider Demographics
NPI:1881835692
Name:LITCHKE, SARAH JAYNE (LADC)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:JAYNE
Last Name:LITCHKE
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 SE 11TH ST
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-3970
Mailing Address - Country:US
Mailing Address - Phone:218-327-1890
Mailing Address - Fax:
Practice Address - Street 1:213 SE 11TH ST
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-3970
Practice Address - Country:US
Practice Address - Phone:218-327-1890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-09
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302575101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
1972792935OtherMEDICA
MN1972792935OtherBCBS
MN1972792935Medicaid
MN1972792935OtherPREFERRED ONE