Healthcare Provider Details

I. General information

NPI: 1083150957
Provider Name (Legal Business Name): SADIE BUBOLTZ-DUBS DAT, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2017
Last Update Date: 04/30/2020
Certification Date: 04/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 NICOLET DR
GREEN BAY WI
54311-7003
US

IV. Provider business mailing address

1348 GEORGE ST
DE PERE WI
54115-3527
US

V. Phone/Fax

Practice location:
  • Phone: 920-377-1544
  • Fax:
Mailing address:
  • Phone: 920-377-1544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1482-39
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: