Provider Demographics
NPI:1194988410
Name:RIVES, SANDRA JEAN SOWADA (OTR)
Entity type:Individual
Prefix:
First Name:SANDRA JEAN
Middle Name:SOWADA
Last Name:RIVES
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3208 BOWWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62712-8944
Mailing Address - Country:US
Mailing Address - Phone:217-585-1678
Mailing Address - Fax:217-732-8041
Practice Address - Street 1:1507 7TH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:IL
Practice Address - Zip Code:62656-2216
Practice Address - Country:US
Practice Address - Phone:217-732-4826
Practice Address - Fax:217-732-8041
Is Sole Proprietor?:No
Enumeration Date:2008-07-07
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.008030174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist