Provider Demographics
NPI:1801887591
Name:LAU, SARAH BENNETT (PHD)
Entity type:Individual
Prefix:DR
First Name:SARAH
Middle Name:BENNETT
Last Name:LAU
Suffix:
Gender:F
Credentials:PHD
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 579
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-0579
Mailing Address - Country:US
Mailing Address - Phone:662-895-1707
Mailing Address - Fax:662-893-0388
Practice Address - Street 1:6978 OAK FOREST DR
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-1332
Practice Address - Country:US
Practice Address - Phone:662-895-1707
Practice Address - Fax:662-893-0388
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS33520103TC0700X
TNP00001796103TC0700X
AR93-32P103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00113613Medicaid
TN3687521Medicare ID - Type Unspecified