Provider Demographics
NPI:1215291513
Name:DIEBOLD, SARA L (DPT)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:L
Last Name:DIEBOLD
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6840 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60516-3425
Mailing Address - Country:US
Mailing Address - Phone:630-275-8480
Mailing Address - Fax:630-275-8489
Practice Address - Street 1:6840 MAIN ST
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60516-3425
Practice Address - Country:US
Practice Address - Phone:630-275-8480
Practice Address - Fax:630-275-8489
Is Sole Proprietor?:No
Enumeration Date:2012-07-02
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
IL070-019188225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL12403921OtherCAQH PROVIDER NUMBER