Provider Demographics
NPI:1861884439
Name:GREEN, SARA M (MACCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:SARA
Middle Name:M
Last Name:GREEN
Suffix:
Gender:F
Credentials:MACCC-SLP
Other - Prefix:MS
Other - First Name:SARA
Other - Middle Name:M
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MACCC-SLP
Mailing Address - Street 1:5000 ROCKSIDE RD STE 500
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:OH
Mailing Address - Zip Code:44131-2178
Mailing Address - Country:US
Mailing Address - Phone:216-459-2846
Mailing Address - Fax:216-901-2803
Practice Address - Street 1:5520 BROADVIEW RD FRNT
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44134-1605
Practice Address - Country:US
Practice Address - Phone:216-749-6650
Practice Address - Fax:216-749-1655
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-19
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.09405235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH14180170OtherCAQH
OH0259115Medicaid