MEDICARE: SARA BLACKMAN

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	235Z00000X	Speech-Language Pathologist	CF586	OK

General Provider Information

NPI Number	:	1902589732
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SARA BLACKMAN

Provider Business Mailing Address
First Line	:	1304 S TYLER AVE
Second Line	:
City	:	WAGONER
State	:	OK
Zip	:	74467-7823
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	405 E RICHMOND ST
Second Line	:
City	:	BROKEN ARROW
State	:	OK
Zip	:	74012-5642
Country	:	US
Telephone Number	:	479-883-4527
Fax Number	:

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

Provider Enumeration Date	:	08/09/2023
Last Update Date	:	08/09/2023

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Directions to “ SARA BLACKMAN ” Practice Location

Language	Start Address	Practice Location

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