Provider Demographics
NPI:1316497449
Name:DETHLOFF, SARAH ANN (MS, ATC, LAT, CES)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:ANN
Last Name:DETHLOFF
Suffix:
Gender:F
Credentials:MS, ATC, LAT, CES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 WITHERS WAY
Mailing Address - Street 2:
Mailing Address - City:KRUM
Mailing Address - State:TX
Mailing Address - Zip Code:76249-6845
Mailing Address - Country:US
Mailing Address - Phone:940-210-5664
Mailing Address - Fax:
Practice Address - Street 1:1200 BOBCAT BLVD
Practice Address - Street 2:
Practice Address - City:KRUM
Practice Address - State:TX
Practice Address - Zip Code:76249-6908
Practice Address - Country:US
Practice Address - Phone:940-482-2611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-13
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT55022255A2300X
TX20000153972255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer