Provider Demographics
NPI:1114084803
Name:DWORKIN, SARI HERMINE (PHD)
Entity Type:Individual
Prefix:DR
First Name:SARI
Middle Name:HERMINE
Last Name:DWORKIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:791 PRICE ST # 166
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-2529
Mailing Address - Country:US
Mailing Address - Phone:559-930-1747
Mailing Address - Fax:805-773-5427
Practice Address - Street 1:1985 JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4131
Practice Address - Country:US
Practice Address - Phone:559-930-1747
Practice Address - Fax:805-773-5427
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC23370106H00000X
CA13852103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFE260AMedicare UPIN