Provider Demographics
NPI:1699868539
Name:VAN WORMER, SARA LYNN (MA, LLP)
Entity type:Individual
Prefix:MS
First Name:SARA
Middle Name:LYNN
Last Name:VAN WORMER
Suffix:
Gender:F
Credentials:MA, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:629 FARMDALE ST
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-1856
Mailing Address - Country:US
Mailing Address - Phone:248-763-4565
Mailing Address - Fax:
Practice Address - Street 1:2550 S TELEGRAPH RD
Practice Address - Street 2:SUITE 250
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-0950
Practice Address - Country:US
Practice Address - Phone:248-322-0001
Practice Address - Fax:248-322-0004
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011371103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist