MEDICARE: SARA BRANSON PRIMEAU LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	34001838A	IN

General Provider Information

NPI Number	:	1720394018
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SARA BRANSON PRIMEAU LCSW

Provider Business Mailing Address
First Line	:	1232 CATULA AVE
Second Line	:
City	:	LAFAYETTE
State	:	IN
Zip	:	47905-1922
Country	:	US
Telephone Number	:	765-409-6274
Fax Number	:

Provider Business Practice Location Address
First Line	:	133 N 4TH ST
Second Line	:	SUITE 407
City	:	LAFAYETTE
State	:	IN
Zip	:	47901-1371
Country	:	US
Telephone Number	:	765-409-6274
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/24/2010
Last Update Date	:	08/24/2010

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