Provider Demographics
NPI:1336900554
Name:PURCELL, SARAH M (MS, RDS, IBCLC)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:M
Last Name:PURCELL
Suffix:
Gender:F
Credentials:MS, RDS, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7372 KIPLING ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48206-2625
Mailing Address - Country:US
Mailing Address - Phone:734-546-2742
Mailing Address - Fax:
Practice Address - Street 1:28625 NORTHWESTERN HWY STE 100
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-8351
Practice Address - Country:US
Practice Address - Phone:248-645-1740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-16
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI86063796133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered