Provider Demographics
NPI:1912404781
Name:WALTER SHIHDANIAN, SARA ELIZABETH (MS, LMHC)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:ELIZABETH
Last Name:WALTER SHIHDANIAN
Suffix:
Gender:F
Credentials:MS, LMHC
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:ELIZABETH
Other - Last Name:RUNDLETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1123 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-3209
Mailing Address - Country:US
Mailing Address - Phone:612-963-3861
Mailing Address - Fax:
Practice Address - Street 1:1123 WEST AVE
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3209
Practice Address - Country:US
Practice Address - Phone:612-963-3861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR5175101YM0800X
WA60111072101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health