Provider Demographics
NPI:1508516774
Name:MOUTRANE, SARA A
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:A
Last Name:MOUTRANE
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 1:610 ZINNIA DR
Mailing Address - Street 2:
Mailing Address - City:CASSELBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32707-5058
Mailing Address - Country:US
Mailing Address - Phone:518-536-2727
Mailing Address - Fax:
Practice Address - Street 1:1701 PARK CENTER DR STE 202
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-6235
Practice Address - Country:US
Practice Address - Phone:407-286-2021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-28
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113156100Medicaid