Healthcare Provider Details

I. General information

NPI: 1295218451
Provider Name (Legal Business Name): MRS. SARA BETH MICHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2018
Last Update Date: 09/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1045 KLOTZ RD
BOWLING GREEN OH
43402-4820
US

IV. Provider business mailing address

1948 COOPERS HAWK RD
PERRYSBURG OH
43551-2094
US

V. Phone/Fax

Practice location:
  • Phone: 419-352-7588
  • Fax: 419-354-4977
Mailing address:
  • Phone: 763-464-3371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC.1801031-TRNE
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: