Provider Demographics
NPI:1184180507
Name:GEORGE, SARENA LAVONNE
Entity Type:Individual
Prefix:MS
First Name:SARENA
Middle Name:LAVONNE
Last Name:GEORGE
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 1:4054 SW 69TH WAY
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33023-6642
Mailing Address - Country:US
Mailing Address - Phone:954-274-1537
Mailing Address - Fax:
Practice Address - Street 1:4054 SW 69TH WAY
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33023-6642
Practice Address - Country:US
Practice Address - Phone:954-274-1537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL8153Medicaid