Provider Demographics
NPI:1053043851
Name:REZNECHEK, SARAH
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:REZNECHEK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1211
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32459-1211
Mailing Address - Country:US
Mailing Address - Phone:320-248-0213
Mailing Address - Fax:
Practice Address - Street 1:215 WAYNE TRL
Practice Address - Street 2:
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459-5041
Practice Address - Country:US
Practice Address - Phone:320-248-0213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-29
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN17400104100000X
MN4317121041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty