Provider Demographics
NPI:1124590823
Name:MOULDER, SARA (OTR/L)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:MOULDER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4192 PALMETTO DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40513-1303
Mailing Address - Country:US
Mailing Address - Phone:859-684-5311
Mailing Address - Fax:
Practice Address - Street 1:2050 VERSAILLES RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-1405
Practice Address - Country:US
Practice Address - Phone:859-254-5701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-19
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY175083225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist