Provider Demographics
NPI:1922440908
Name:GRAVATT-WIMSATT, SARA BETH (MA)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:BETH
Last Name:GRAVATT-WIMSATT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:BETH
Other - Last Name:GRAVATT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:99 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01852-2621
Mailing Address - Country:US
Mailing Address - Phone:978-458-6282
Mailing Address - Fax:978-441-9826
Practice Address - Street 1:99 CHURCH ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-2621
Practice Address - Country:US
Practice Address - Phone:978-458-6282
Practice Address - Fax:978-441-9826
Is Sole Proprietor?:No
Enumeration Date:2013-07-19
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110027968AMedicaid