Provider Demographics
NPI:1831827484
Name:STOCKWELL, SARA J (EDS)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:J
Last Name:STOCKWELL
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 E WATER ST
Mailing Address - Street 2:
Mailing Address - City:OAK HARBOR
Mailing Address - State:OH
Mailing Address - Zip Code:43449-1534
Mailing Address - Country:US
Mailing Address - Phone:419-261-7272
Mailing Address - Fax:
Practice Address - Street 1:1070 COMMERCE DR STE 301
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-5284
Practice Address - Country:US
Practice Address - Phone:419-931-3029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-11
Last Update Date:2024-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.00693103T00000X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No103T00000XBehavioral Health & Social Service ProvidersPsychologist