Provider Demographics
NPI:1538701099
Name:SPICER, SARAH ANN
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:ANN
Last Name:SPICER
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 1:9678 CLYDE PARK AVE SW
Mailing Address - Street 2:
Mailing Address - City:BYRON CENTER
Mailing Address - State:MI
Mailing Address - Zip Code:49315-9204
Mailing Address - Country:US
Mailing Address - Phone:248-345-0089
Mailing Address - Fax:
Practice Address - Street 1:790 FULLER AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1918
Practice Address - Country:US
Practice Address - Phone:616-855-5845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-16
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
57721225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist