Provider Demographics
NPI:1245406016
Name:HIXSON, SARAH RANDOLPH (LCSW)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:RANDOLPH
Last Name:HIXSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:R
Other - Last Name:HIXSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 856
Mailing Address - Street 2:
Mailing Address - City:PINEDALE
Mailing Address - State:WY
Mailing Address - Zip Code:82941-0856
Mailing Address - Country:US
Mailing Address - Phone:307-367-2111
Mailing Address - Fax:307-367-2166
Practice Address - Street 1:24 COUNTRY CLUB LANE
Practice Address - Street 2:
Practice Address - City:PINEDALE
Practice Address - State:WY
Practice Address - Zip Code:82941
Practice Address - Country:US
Practice Address - Phone:307-367-2111
Practice Address - Fax:307-367-2166
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-01
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLCSW 276104100000X
261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder