Provider Demographics
NPI:1801108857
Name:WIVELL, SARA M (LMT)
Entity type:Individual
Prefix:MS
First Name:SARA
Middle Name:M
Last Name:WIVELL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6921 ENVIRON BLVD
Mailing Address - Street 2:3N
Mailing Address - City:LAUDERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33319-4248
Mailing Address - Country:US
Mailing Address - Phone:954-326-1421
Mailing Address - Fax:
Practice Address - Street 1:570 OCEAN DR
Practice Address - Street 2:#501
Practice Address - City:JUNO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33408-1952
Practice Address - Country:US
Practice Address - Phone:954-476-6401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-07
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL59254OtherLICENSED MASSAGE THERAPIST