1144760604 NPI number — SARAH FREDERICK MSW

Table of content: SARAH FREDERICK MSW (NPI 1144760604)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144760604 NPI number — SARAH FREDERICK MSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FREDERICK
Provider First Name:
SARAH
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GULBRANSON
Provider Other First Name:
SARAH
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1144760604
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2600 W CENTRE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTAGE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49024-4828
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-324-4141
Provider Business Mailing Address Fax Number:
269-324-2020

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2600 W CENTRE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTAGE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49024-4828
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-324-4141
Provider Business Practice Location Address Fax Number:
269-324-2020
Provider Enumeration Date:
03/03/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  6801086245 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)