Provider Demographics
NPI:1275797490
Name:FORTIN, SARA CATHERINE (MS)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:CATHERINE
Last Name:FORTIN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 LUNA AVE
Mailing Address - Street 2:APT. 201
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-4590
Mailing Address - Country:US
Mailing Address - Phone:760-717-8739
Mailing Address - Fax:
Practice Address - Street 1:221 LUNA AVE
Practice Address - Street 2:APT. 201
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462
Practice Address - Country:US
Practice Address - Phone:760-717-8739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-16
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0717001229106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist