Provider Demographics
NPI:1306428255
Name:SUPPES, SARAH DIANE (ATC)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:DIANE
Last Name:SUPPES
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:397 MEADOWS RD N
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-1158
Mailing Address - Country:US
Mailing Address - Phone:815-975-0574
Mailing Address - Fax:
Practice Address - Street 1:400 RIVERSIDE DR STE 1600
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-5406
Practice Address - Country:US
Practice Address - Phone:815-802-7090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-21
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0050982255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer