Healthcare Provider Details

I. General information

NPI: 1740721885
Provider Name (Legal Business Name): SARAH LIVELY CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2017
Last Update Date: 01/12/2024
Certification Date: 01/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 NATURE WALK PKWY UNIT 108
ST AUGUSTINE FL
32092-3065
US

IV. Provider business mailing address

111 NATURE WALK PKWY UNIT 108
ST AUGUSTINE FL
32092-3065
US

V. Phone/Fax

Practice location:
  • Phone: 904-729-6759
  • Fax:
Mailing address:
  • Phone: 904-729-6759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA14057
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: