Provider Demographics
NPI:1063459642
Name:MCCLAM, SARA (LISW AP CP)
Entity Type:Individual
Prefix:MS
First Name:SARA
Middle Name:
Last Name:MCCLAM
Suffix:
Gender:F
Credentials:LISW AP CP
Other - Prefix:MS
Other - First Name:SARA
Other - Middle Name:M
Other - Last Name:MICKELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:334 TOMBFIELD RD
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:SC
Mailing Address - Zip Code:29020
Mailing Address - Country:US
Mailing Address - Phone:803-713-3410
Mailing Address - Fax:803-905-5653
Practice Address - Street 1:1250 WILSON HALL RD
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-1889
Practice Address - Country:US
Practice Address - Phone:803-905-5650
Practice Address - Fax:803-905-5653
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC001951104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
P94941Medicare UPIN