Provider Demographics
NPI:1083150957
Name:BUBOLTZ-DUBS, SADIE (DAT, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:SADIE
Middle Name:
Last Name:BUBOLTZ-DUBS
Suffix:
Gender:F
Credentials:DAT, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1348 GEORGE ST
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-3527
Mailing Address - Country:US
Mailing Address - Phone:920-377-1544
Mailing Address - Fax:
Practice Address - Street 1:2420 NICOLET DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-7003
Practice Address - Country:US
Practice Address - Phone:920-377-1544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-16
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1482-392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer