Provider Demographics
NPI:1780372276
Name:FENNELL, SARA CLAIRE (SLP)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:CLAIRE
Last Name:FENNELL
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 IVANHOE DR
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-8718
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:335 OLD RAIL RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:GA
Practice Address - Zip Code:31302-4025
Practice Address - Country:US
Practice Address - Phone:912-421-0140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-24
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL220079235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist