MEDICARE: LIBERTY DONDERS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program	022312-1	NY

General Provider Information

NPI Number	:	1033364781
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LIBERTY DONDERS

Provider Business Mailing Address
First Line	:	210 MILITARY RD
Second Line	:
City	:	SACKETS HARBOR
State	:	NY
Zip	:	13685-9533
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	210 MILITARY RD
Second Line	:
City	:	SACKETS HARBOR
State	:	NY
Zip	:	13685-9533
Country	:	US
Telephone Number	:	315-646-2462
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/21/2008
Last Update Date	:	11/21/2008

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1326291980 — MRS. SARAH CROUCH DEROUIN OTR/L
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Directions to “ LIBERTY DONDERS ” Practice Location

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