Provider Demographics
NPI:1700160769
Name:SMITH, SARA JEAN WENTLAND
Entity Type:Individual
Prefix:MRS
First Name:SARA
Middle Name:JEAN WENTLAND
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:SARA
Other - Middle Name:J
Other - Last Name:WENTLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2990 CAHILL MAIN
Mailing Address - Street 2:SUITE 204
Mailing Address - City:FITCHBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53711-7130
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2990 CAHILL MAIN
Practice Address - Street 2:SUITE 204
Practice Address - City:FITCHBURG
Practice Address - State:WI
Practice Address - Zip Code:53711-7130
Practice Address - Country:US
Practice Address - Phone:608-204-6083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-07
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3615-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist