1912417668 NPI number — SARAH CATHERINE BROADWATER COTA/L

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912417668 NPI number — SARAH CATHERINE BROADWATER COTA/L

Organization/Personal Information

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:
BROADWATER

Provider First Name:
SARAH

Provider Middle Name:
CATHERINE

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:
COTA/L

Provider Gender Code:
F

Provider's Other Name Information

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Provider Other Middle Name:

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NPI Number Information

NPI Number:
1912417668

Entity Type Code:
Individual

Replacement NPI:

Last Update Date:
10/09/2017

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 KAYLOR CIR

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:
FROSTBURG

Provider Business Mailing Address State Name:
MD

Provider Business Mailing Address Postal Code:
21532-2009

Provider Business Mailing Address Country Code:
US

Provider Business Mailing Address Telephone Number:

Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 KAYLOR CIR

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:
FROSTBURG

Provider Business Practice Location Address State Name:
MD

Provider Business Practice Location Address Postal Code:
21532-2009

Provider Business Practice Location Address Country Code:
US

Provider Business Practice Location Address Telephone Number:
301-689-7446

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:
10/09/2017

Additional Information

			
		

Authorized Official

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Provider Taxonomy Codes

Taxonomy code: 224Z00000X , with the licence number: A01905 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .