Provider Demographics
NPI:1558644328
Name:ROSENBERG, SARA MARIE
Entity Type:Individual
Prefix:MRS
First Name:SARA
Middle Name:MARIE
Last Name:ROSENBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:SARA
Other - Middle Name:MARIE
Other - Last Name:KLOTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1226 STANLEY ST
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-7126
Mailing Address - Country:US
Mailing Address - Phone:574-621-8242
Mailing Address - Fax:
Practice Address - Street 1:2012 IRONWOOD CIR
Practice Address - Street 2:SUITE 230
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1888
Practice Address - Country:US
Practice Address - Phone:574-387-4049
Practice Address - Fax:574-387-4062
Is Sole Proprietor?:No
Enumeration Date:2011-09-27
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99048784A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN99048784AOtherINDIANA PROFESSIONAL LICENSING AGENCY