Provider Demographics
NPI:1447537220
Name:SARA PATTAVINA MOULTON, LIMHP, P.C.
Entity type:Organization
Organization Name:SARA PATTAVINA MOULTON, LIMHP, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:E
Authorized Official - Last Name:PATTAVINA MOULTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-312-0177
Mailing Address - Street 1:1804 S 116TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-2902
Mailing Address - Country:US
Mailing Address - Phone:402-312-0177
Mailing Address - Fax:402-939-0141
Practice Address - Street 1:1804 S 116TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-2902
Practice Address - Country:US
Practice Address - Phone:402-312-0177
Practice Address - Fax:402-939-0141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-08
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026137800Medicaid
NE10026137800Medicaid