Provider Demographics
NPI:1275572687
Name:BROCKBANK, SARA K (OT)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:K
Last Name:BROCKBANK
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8254 ATLEE RD
Mailing Address - Street 2:
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23116-1844
Mailing Address - Country:US
Mailing Address - Phone:804-342-4300
Mailing Address - Fax:804-342-4316
Practice Address - Street 1:8254 ATLEE RD
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116-1844
Practice Address - Country:US
Practice Address - Phone:804-342-4300
Practice Address - Fax:804-342-4316
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119003827225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0119003827OtherLICENSE