Provider Demographics
NPI:1114209699
Name:BANNON, SARA LYNN
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:LYNN
Last Name:BANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 FAIRVIEW TER
Mailing Address - Street 2:
Mailing Address - City:GREAT BARRINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01230-1264
Mailing Address - Country:US
Mailing Address - Phone:413-329-4840
Mailing Address - Fax:
Practice Address - Street 1:19 FAIRVIEW TER
Practice Address - Street 2:
Practice Address - City:GREAT BARRINGTON
Practice Address - State:MA
Practice Address - Zip Code:01230-1264
Practice Address - Country:US
Practice Address - Phone:413-329-4840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-12
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA436236222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist