Provider Demographics
NPI:1922751031
Name:SMITH, SARA JEANETTE (COTA)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:JEANETTE
Last Name:SMITH
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54765 NOTTAWA RD
Mailing Address - Street 2:
Mailing Address - City:MENDON
Mailing Address - State:MI
Mailing Address - Zip Code:49072-9547
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:54765 NOTTAWA RD
Practice Address - Street 2:
Practice Address - City:MENDON
Practice Address - State:MI
Practice Address - Zip Code:49072-9547
Practice Address - Country:US
Practice Address - Phone:260-214-1258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-28
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224ZE0001XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantEnvironmental Modification
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant