Healthcare Provider Details

I. General information

NPI: 1407286651
Provider Name (Legal Business Name): SARAH WIBBENMEYER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2013
Last Update Date: 07/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 SUMMIT ST
OLNEY IL
62450-2028
US

IV. Provider business mailing address

716 N WALNUT ST
OLNEY IL
62450-2044
US

V. Phone/Fax

Practice location:
  • Phone: 618-838-5970
  • Fax:
Mailing address:
  • Phone: 618-838-5970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-19-36840
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: