Provider Demographics
NPI:1053806018
Name:VANTILBURG, SARA
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:VANTILBURG
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 1:211 SALEM RD
Mailing Address - Street 2:
Mailing Address - City:POUND RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:10576-1326
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830-5238
Practice Address - Country:US
Practice Address - Phone:203-629-2822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-22
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health