Healthcare Provider Details

I. General information

NPI: 1639551344
Provider Name (Legal Business Name): SARA ALLYN SHRIVASTAV
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2015
Last Update Date: 06/24/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 E 3RD ST
BLOOMINGTON IN
47401-5539
US

IV. Provider business mailing address

2815 E 3RD ST # 1011
BLOOMINGTON IN
47401-5434
US

V. Phone/Fax

Practice location:
  • Phone: 812-747-9384
  • Fax: 513-278-5465
Mailing address:
  • Phone: 812-747-9384
  • Fax: 513-278-5465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number11727877
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: