Provider Demographics
NPI:1295965846
Name:HUSBY, SARA I (COTA/L)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:I
Last Name:HUSBY
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1920 ROOSEVELT DR APT 54
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55057-3512
Mailing Address - Country:US
Mailing Address - Phone:218-396-0351
Mailing Address - Fax:
Practice Address - Street 1:815 FOREST AVE
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55057-1643
Practice Address - Country:US
Practice Address - Phone:507-664-8800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-16
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN201299313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN201299Medicaid