Provider Demographics
NPI:1285664482
Name:ROTENBERRY, SARA JEAN (LCSW)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:JEAN
Last Name:ROTENBERRY
Suffix:
Gender:F
Credentials:LCSW
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 835840
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75083-5840
Mailing Address - Country:US
Mailing Address - Phone:972-680-1577
Mailing Address - Fax:972-690-9834
Practice Address - Street 1:1313 SEMINOLE DR
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-3736
Practice Address - Country:US
Practice Address - Phone:214-912-1452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX198141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00787EMedicare ID - Type Unspecified