Provider Demographics
NPI:1639551344
Name:SHRIVASTAV, SARA ALLYN
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:ALLYN
Last Name:SHRIVASTAV
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 1:2815 E 3RD ST # 1011
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-5434
Mailing Address - Country:US
Mailing Address - Phone:812-747-9384
Mailing Address - Fax:513-278-5465
Practice Address - Street 1:4101 E 3RD ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-5539
Practice Address - Country:US
Practice Address - Phone:812-747-9384
Practice Address - Fax:513-278-5465
Is Sole Proprietor?:No
Enumeration Date:2015-06-18
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11727877103K00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst