Provider Demographics
NPI:1801404355
Name:UNDEM, SARA LOIS
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:LOIS
Last Name:UNDEM
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 1:13002 PURDY DR NW
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98332-8618
Mailing Address - Country:US
Mailing Address - Phone:253-777-8993
Mailing Address - Fax:
Practice Address - Street 1:3704 N 35TH ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98407-6033
Practice Address - Country:US
Practice Address - Phone:253-312-8909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-21
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician