=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962515510
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SARA L. SPURLOCK OTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2006
-----------------------------------------------------
Last Update Date | 07/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 593 WINDRIDGE RD
-----------------------------------------------------
City | GILMER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75645-6949
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-845-7835
-----------------------------------------------------
Fax | 866-805-3093
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 9625
-----------------------------------------------------
City | LONGVIEW
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75608-9625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-845-7835
-----------------------------------------------------
Fax | 866-805-3093
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225XP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Occupational Therapist
-----------------------------------------------------
License Number | 103105
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------