Provider Demographics
NPI:1932128501
Name:FAVORITE, SARA RUTH (PHD)
Entity Type:Individual
Prefix:DR
First Name:SARA
Middle Name:RUTH
Last Name:FAVORITE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:SARA
Other - Middle Name:RUTH
Other - Last Name:STEVENSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:5625 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209
Mailing Address - Country:US
Mailing Address - Phone:210-264-5122
Mailing Address - Fax:210-822-7321
Practice Address - Street 1:5625 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209
Practice Address - Country:US
Practice Address - Phone:210-264-5122
Practice Address - Fax:210-822-7321
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32427103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1690638-01Medicaid
TX8C7734Medicare ID - Type Unspecified
TX1690638-01Medicaid
TX612842Medicare UPIN
TX86926AMedicare UPIN