Provider Demographics
NPI:1093317521
Name:WILLENKIN, SARA
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:WILLENKIN
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 1:7480 ALOMA AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-9102
Mailing Address - Country:US
Mailing Address - Phone:407-951-9441
Mailing Address - Fax:
Practice Address - Street 1:7480 ALOMA AVE
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-9102
Practice Address - Country:US
Practice Address - Phone:321-972-4039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-10
Last Update Date:2023-05-03
Deactivation Date:2023-02-22
Deactivation Code:
Reactivation Date:2023-03-28
Provider Licenses
StateLicense IDTaxonomies
FL20-136470106S00000X
FLIMH23743101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician