Healthcare Provider Details

I. General information

NPI: 1063014744
Provider Name (Legal Business Name): SARA ANN MCQUILLIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2020
Last Update Date: 11/09/2020
Certification Date: 11/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 GARDEN ST STE B
CRESTVIEW FL
32536-1755
US

IV. Provider business mailing address

416 GARDEN ST STE B
CRESTVIEW FL
32536-1755
US

V. Phone/Fax

Practice location:
  • Phone: 808-729-6398
  • Fax: 850-331-1480
Mailing address:
  • Phone: 808-729-6398
  • Fax: 850-331-1480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-20-44736
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: