Provider Demographics
NPI:1992342398
Name:RUSSELL, SARAH LYNN (BSW, LMSW)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:LYNN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:BSW, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4383 W 49TH S
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-5726
Mailing Address - Country:US
Mailing Address - Phone:208-520-6823
Mailing Address - Fax:
Practice Address - Street 1:550 W SUNNYSIDE RD STE 1
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-4642
Practice Address - Country:US
Practice Address - Phone:208-529-5777
Practice Address - Fax:208-529-5778
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-04
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW38260104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker