Provider Demographics
NPI:1457098006
Name:POULSON, SIERRA M (LSW)
Entity type:Individual
Prefix:
First Name:SIERRA
Middle Name:M
Last Name:POULSON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:SIERRA
Other - Middle Name:M
Other - Last Name:SHAFFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LSW
Mailing Address - Street 1:1158 WESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:VAN WERT
Mailing Address - State:OH
Mailing Address - Zip Code:45891-2449
Mailing Address - Country:US
Mailing Address - Phone:419-238-3434
Mailing Address - Fax:
Practice Address - Street 1:1158 WESTWOOD DR
Practice Address - Street 2:
Practice Address - City:VAN WERT
Practice Address - State:OH
Practice Address - Zip Code:45891-2449
Practice Address - Country:US
Practice Address - Phone:419-238-3434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-16
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OHS.23098211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator