Provider Demographics
NPI:1952015174
Name:COULTER, SARA GRACE (RBT)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:GRACE
Last Name:COULTER
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3306 VANTAGE POINT DR APT 3B
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-7311
Mailing Address - Country:US
Mailing Address - Phone:317-730-5796
Mailing Address - Fax:
Practice Address - Street 1:201 E RUDISILL BLVD # B100
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46806-1738
Practice Address - Country:US
Practice Address - Phone:260-255-3665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-11
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-21-154550106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician