Provider Demographics
NPI:1528219797
Name:MACULLOCH, SARA M
Entity Type:Individual
Prefix:MISS
First Name:SARA
Middle Name:M
Last Name:MACULLOCH
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 1:200 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-5722
Mailing Address - Country:US
Mailing Address - Phone:570-760-7275
Mailing Address - Fax:
Practice Address - Street 1:200 2ND AVE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-5722
Practice Address - Country:US
Practice Address - Phone:570-760-7275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-07
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE006951225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant