Provider Demographics
NPI:1780988170
Name:ERVIN, SARA JO (COTA)
Entity type:Individual
Prefix:MRS
First Name:SARA
Middle Name:JO
Last Name:ERVIN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2703 WILLOW OAKS DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46809-1844
Mailing Address - Country:US
Mailing Address - Phone:260-747-6533
Mailing Address - Fax:
Practice Address - Street 1:2703 WILLOW OAKS DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46809-1844
Practice Address - Country:US
Practice Address - Phone:260-747-6533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-29
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001419A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant