Provider Demographics
NPI:1497815443
Name:PATTAVINA MOULTON, SARA E
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:E
Last Name:PATTAVINA MOULTON
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 1:1804 S 116TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-2902
Mailing Address - Country:US
Mailing Address - Phone:402-312-0177
Mailing Address - Fax:
Practice Address - Street 1:1804 S 116TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-2902
Practice Address - Country:US
Practice Address - Phone:402-312-0177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE3067104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker