Provider Demographics
NPI:1811358195
Name:HIATT, SARA JEAN (LCSW)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:JEAN
Last Name:HIATT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:JEAN
Other - Last Name:PICANCO-HIATT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:960 SAFSTROM DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4141
Mailing Address - Country:US
Mailing Address - Phone:208-589-0936
Mailing Address - Fax:
Practice Address - Street 1:3355 S HOLMES AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7981
Practice Address - Country:US
Practice Address - Phone:208-523-2080
Practice Address - Fax:208-523-2799
Is Sole Proprietor?:No
Enumeration Date:2016-03-14
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-355451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical