Provider Demographics
NPI:1720450414
Name:CORCORAN, SARA NICOLE (MS)
Entity Type:Individual
Prefix:MRS
First Name:SARA
Middle Name:NICOLE
Last Name:CORCORAN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 TUMBLEWEED TRL
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:IA
Mailing Address - Zip Code:50677-9506
Mailing Address - Country:US
Mailing Address - Phone:319-239-9128
Mailing Address - Fax:
Practice Address - Street 1:405 TUMBLEWEED TRL
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:IA
Practice Address - Zip Code:50677-9506
Practice Address - Country:US
Practice Address - Phone:319-239-9128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-21
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.011164235Z00000X
IA002120235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist