Healthcare Provider Details

I. General information

NPI: 1457948309
Provider Name (Legal Business Name): SARAH ELIZABETH VELGUTH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2020
Last Update Date: 12/27/2020
Certification Date: 12/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 NE ROBERTS AVE APT 219
GRESHAM OR
97030-5622
US

IV. Provider business mailing address

1827 NE 44TH AVE STE 390
PORTLAND OR
97213-1461
US

V. Phone/Fax

Practice location:
  • Phone: 262-366-3319
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberABA-IN-10210769
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: