Healthcare Provider Details

I. General information

NPI: 1124728548
Provider Name (Legal Business Name): SARAH LORRAINE ZHUKOV
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SARAH WAYER

II. Dates (important events)

Enumeration Date: 03/06/2023
Last Update Date: 03/06/2023
Certification Date: 03/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 W JORDAN ST STE 110B
PENSACOLA FL
32501-1740
US

IV. Provider business mailing address

6101 STAFF RD
CRESTVIEW FL
32536-4307
US

V. Phone/Fax

Practice location:
  • Phone: 850-472-2507
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: