Provider Demographics
NPI:1336637214
Name:MUCCILLO, SARAH (MS, ATC, LAT)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:MUCCILLO
Suffix:
Gender:F
Credentials:MS, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 LAUREL CANYON VILLAGE CIR APT 5203
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-4606
Mailing Address - Country:US
Mailing Address - Phone:770-842-7903
Mailing Address - Fax:
Practice Address - Street 1:30 LAUREL CANYON VILLAGE CIR APT 5203
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-4606
Practice Address - Country:US
Practice Address - Phone:770-842-7903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-26
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0027712255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer