Provider Demographics
NPI:1114125705
Name:BLAGG, SARAH ELLEN (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:SARAH
Middle Name:ELLEN
Last Name:BLAGG
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:PO BOX 2518
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72654-2518
Mailing Address - Country:US
Mailing Address - Phone:870-404-5870
Mailing Address - Fax:
Practice Address - Street 1:2203 RUSSELL LN
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-9250
Practice Address - Country:US
Practice Address - Phone:870-404-5870
Practice Address - Fax:870-430-5934
Is Sole Proprietor?:No
Enumeration Date:2007-07-05
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2269235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5Y010OtherARKANSAS BLUE CROSS AND BLUE SHIELD
AR154456721Medicaid