Provider Demographics
NPI:1154924991
Name:MCINNIS, SARA (PT)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:MCINNIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:
Other - Last Name:SPERN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:805 ELM ST
Mailing Address - Street 2:
Mailing Address - City:LAKE MILLS
Mailing Address - State:WI
Mailing Address - Zip Code:53551-1127
Mailing Address - Country:US
Mailing Address - Phone:920-648-2400
Mailing Address - Fax:920-648-2444
Practice Address - Street 1:805 ELM ST
Practice Address - Street 2:
Practice Address - City:LAKE MILLS
Practice Address - State:WI
Practice Address - Zip Code:53551-1127
Practice Address - Country:US
Practice Address - Phone:920-648-2400
Practice Address - Fax:920-648-2444
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15286-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI15286-24OtherSTATE PHYSICAL THERAPY LICENSE NUMBER