Provider Demographics
NPI:1396283040
Name:DENNIS, SARA JENAE
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:JENAE
Last Name:DENNIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 E GLASS RD
Mailing Address - Street 2:
Mailing Address - City:ORTONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48462-8877
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:162 SOUTH ST
Practice Address - Street 2:
Practice Address - City:ORTONVILLE
Practice Address - State:MI
Practice Address - Zip Code:48462-8530
Practice Address - Country:US
Practice Address - Phone:248-240-5698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-02
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI103K00000X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician