Provider Demographics
NPI:1194096107
Name:BORELLA TUCKER, SARA K (MED, BCBA)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:K
Last Name:BORELLA TUCKER
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:K
Other - Last Name:BORELLA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MED, BCBA
Mailing Address - Street 1:4317 BANISTER LN UNIT A
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-1006
Mailing Address - Country:US
Mailing Address - Phone:512-965-1231
Mailing Address - Fax:
Practice Address - Street 1:1700 RIO GRANDE ST
Practice Address - Street 2:200
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78701-1124
Practice Address - Country:US
Practice Address - Phone:512-732-8400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-23
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11211614103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst