Provider Demographics
NPI:1295288835
Name:SPIVAK, SARA M (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:M
Last Name:SPIVAK
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:M
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:2000 MEDICAL PKWY
Mailing Address - Street 2:BELCHER PAVILION, SUITE 404
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-3742
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2000 MEDICAL PKWY
Practice Address - Street 2:BELCHER PAVILION, SUITE 404
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401
Practice Address - Country:US
Practice Address - Phone:443-481-1140
Practice Address - Fax:443-481-1148
Is Sole Proprietor?:No
Enumeration Date:2016-08-01
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD08231235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD541508ZRKTMedicare PIN
MD534213ZR1SMedicare PIN