1154430668 NPI number — SARAH GASSMAN WILBANKS OTR/L

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154430668 NPI number — SARAH GASSMAN WILBANKS OTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILBANKS
Provider First Name:
SARAH
Provider Middle Name:
GASSMAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR/L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154430668
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/02/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9 N BASILICA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HANAHAN
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29410-8649
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-478-4047
Provider Business Mailing Address Fax Number:
843-762-7074

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
408 FOLLY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29412-2625
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-762-3601
Provider Business Practice Location Address Fax Number:
843-762-7074
Provider Enumeration Date:
08/29/2006

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: 225X00000X , with the licence number:  1567 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: TH0665 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com