Healthcare Provider Details

I. General information

NPI: 1093317521
Provider Name (Legal Business Name): SARA WILLENKIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2020
Last Update Date: 08/20/2024
Certification Date: 08/20/2024
Deactivation Date: 02/22/2023
Reactivation Date: 03/28/2023

III. Provider practice location address

2487 ALOMA AVE
WINTER PARK FL
32792-2542
US

IV. Provider business mailing address

12704 WATERFORD WILLOW LN APT 202
ORLANDO FL
32828-6075
US

V. Phone/Fax

Practice location:
  • Phone: 321-207-0435
  • Fax:
Mailing address:
  • Phone: 407-951-9441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number20-136470
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH23743
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: