Provider Demographics
NPI:1790141703
Name:ELIASON, SARA
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:ELIASON
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 1:726 APACHE AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:RATON
Mailing Address - State:NM
Mailing Address - Zip Code:87740-4059
Mailing Address - Country:US
Mailing Address - Phone:505-334-3695
Mailing Address - Fax:
Practice Address - Street 1:726 APACHE AVE APT 1
Practice Address - Street 2:
Practice Address - City:RATON
Practice Address - State:NM
Practice Address - Zip Code:87740-4059
Practice Address - Country:US
Practice Address - Phone:505-334-3695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-06
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5892235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist