MEDICARE: MRS. SARA LYNN BUCKWALTER BRAVO MS OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225XM0800X	Mental Health Occupational Therapist	OC010940	PA
2	225XP0200X	Pediatric Occupational Therapist	025705	NY

General Provider Information

NPI Number	:	1417191388
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SARA LYNN BUCKWALTER BRAVO MS OTR/L

Provider Business Mailing Address
First Line	:	95202A HUDSON LN
Second Line	:
City	:	FORT DRUM
State	:	NY
Zip	:	13603-3041
Country	:	US
Telephone Number	:	717-572-9813
Fax Number	:

Provider Business Practice Location Address
First Line	:	95202A HUDSON LN
Second Line	:
City	:	FORT DRUM
State	:	NY
Zip	:	13603-3041
Country	:	US
Telephone Number	:	717-572-9813
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/23/2009
Last Update Date	:	09/28/2021

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