Basic Information
Provider Information | |||||||||
NPI: | 1912179128 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WEISENBACH | ||||||||
FirstName: | SARA | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WRIGHT | ||||||||
OtherFirstName: | SARA | ||||||||
OtherMiddleName: | LOUISE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PH..D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1559 | ||||||||
Address2: |   | ||||||||
City: | STONY BROOK | ||||||||
State: | NY | ||||||||
PostalCode: | 117900989 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6316382035 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 169 PUTNAM HALL | ||||||||
Address2: |   | ||||||||
City: | STONY BROOK | ||||||||
State: | NY | ||||||||
PostalCode: | 11790 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8005255188 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/27/2008 | ||||||||
LastUpdateDate: | 03/02/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/02/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | 6301013024 | MI | N |   | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |   | 103TC0700X | 6301013024 | MI | N |   | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103G00000X | 023615 | NY | Y |   | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |   |
No ID Information.