Basic Information
| Provider Information | |||||||||
| NPI: | 1811460785 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLOM | ||||||||
| FirstName: | SARAH | ||||||||
| MiddleName: | FIREBAUGH | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ATC, CSCS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FIREBAUGH | ||||||||
| OtherFirstName: | SARAH | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | ATC, CSCS | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1115 BOULDERS PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | NORTH CHESTERFIELD | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232254067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8044332080 | ||||||||
| FaxNumber: | 8047943708 | ||||||||
| Practice Location | |||||||||
| Address1: | 1115 BOULDERS PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | NORTH CHESTERFIELD | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232254067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8044332080 | ||||||||
| FaxNumber: | 8047943708 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2019 | ||||||||
| LastUpdateDate: | 01/03/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 0126000933 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.