Healthcare Provider Details

I. General information

NPI: 1306428255
Provider Name (Legal Business Name): SARAH DIANE SUPPES ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2021
Last Update Date: 04/21/2021
Certification Date: 04/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 RIVERSIDE DR STE 1600
BOURBONNAIS IL
60914-5406
US

IV. Provider business mailing address

397 MEADOWS RD N
BOURBONNAIS IL
60914-1158
US

V. Phone/Fax

Practice location:
  • Phone: 815-802-7090
  • Fax:
Mailing address:
  • Phone: 815-975-0574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096.005098
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: