Provider Demographics
NPI:1366934028
Name:WUNDERLICH, SARAH MICHELLE (LISW)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:MICHELLE
Last Name:WUNDERLICH
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:MICHELLE
Other - Last Name:HOLMES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LISW
Mailing Address - Street 1:700 BROOKSEDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-2820
Mailing Address - Country:US
Mailing Address - Phone:614-245-5210
Mailing Address - Fax:
Practice Address - Street 1:700 BROOKSEDGE BLVD
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-2820
Practice Address - Country:US
Practice Address - Phone:614-245-5210
Practice Address - Fax:614-882-3402
Is Sole Proprietor?:No
Enumeration Date:2018-05-30
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.18013081041C0700X
OH1100716104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1366934028Medicaid