=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487130720
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SARA JANE LUTAT MSW, MLADC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2018
-----------------------------------------------------
Last Update Date | 07/18/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 102 4TH ST
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03102-4540
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-782-3004
-----------------------------------------------------
Fax | 603-518-8977
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 155 W CLARKE ST APT 2
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03104-2448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-562-5351
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 1000
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------