Provider Demographics
NPI:1801974217
Name:FELLOWS, SARA ALICE (PCC)
Entity type:Individual
Prefix:MRS
First Name:SARA
Middle Name:ALICE
Last Name:FELLOWS
Suffix:
Gender:F
Credentials:PCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53060 RUANN DR
Mailing Address - Street 2:
Mailing Address - City:SHELBY TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48316-2559
Mailing Address - Country:US
Mailing Address - Phone:330-412-2147
Mailing Address - Fax:
Practice Address - Street 1:3604 CLARKSTON RD. LAKE ORION COUNSELING CENTER
Practice Address - Street 2:3604 CLARKSTON RD.
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48316
Practice Address - Country:US
Practice Address - Phone:248-595-9969
Practice Address - Fax:248-814-0361
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401016814101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2643616Medicaid