Healthcare Provider Details

I. General information

NPI: 1659802148
Provider Name (Legal Business Name): SARAH MENNELLA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2017
Last Update Date: 10/29/2024
Certification Date: 10/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3249 OAK PARK AVE
BERWYN IL
60402-3429
US

IV. Provider business mailing address

109 W 27TH ST SUITE 5S
NEW YORK NY
10001-0715
US

V. Phone/Fax

Practice location:
  • Phone: 708-783-9100
  • Fax:
Mailing address:
  • Phone: 917-634-5311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036150265
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: