Provider Demographics
NPI:1184219297
Name:ELAM, SARA
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:ELAM
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 1:11713 KETTERING DR
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45251-4672
Mailing Address - Country:US
Mailing Address - Phone:513-349-5331
Mailing Address - Fax:
Practice Address - Street 1:10925 REED HARTMAN HWY STE 307
Practice Address - Street 2:
Practice Address - City:BLUE ASH
Practice Address - State:OH
Practice Address - Zip Code:45242-2842
Practice Address - Country:US
Practice Address - Phone:513-888-2501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-02
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2304818101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2910854Medicaid