Provider Demographics
NPI:1811413677
Name:LICHTENWALTER, SARA
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:LICHTENWALTER
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 1:51743 INVERNESS DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46628-9555
Mailing Address - Country:US
Mailing Address - Phone:860-882-2516
Mailing Address - Fax:
Practice Address - Street 1:51743 INVERNESS DR
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46628-9555
Practice Address - Country:US
Practice Address - Phone:860-882-2516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-14
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
IN34009598A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician