Provider Demographics
NPI:1912179128
Name:WEISENBACH, SARA L (PHD)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:L
Last Name:WEISENBACH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:LOUISE
Other - Last Name:WRIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 1559
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-0989
Mailing Address - Country:US
Mailing Address - Phone:631-638-2035
Mailing Address - Fax:
Practice Address - Street 1:169 PUTNAM HALL
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790
Practice Address - Country:US
Practice Address - Phone:800-525-5188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-27
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013024103G00000X, 103TC0700X
NY023615103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical