Provider Demographics
NPI:1003501339
Name:PHILLIPS, SARA (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7583 SIKA DEER WAY
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33966-5719
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 PINE ISLAND RD
Practice Address - Street 2:
Practice Address - City:NORTH FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33903-3740
Practice Address - Country:US
Practice Address - Phone:239-995-2258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-11
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA13158235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty