Provider Demographics
NPI:1104211713
Name:SHAFFER, SARAH (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:SHAFFER
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36415 N HUTCHINS RD
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-1517
Mailing Address - Country:US
Mailing Address - Phone:847-946-3842
Mailing Address - Fax:
Practice Address - Street 1:36415 N HUTCHINS RD
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-1517
Practice Address - Country:US
Practice Address - Phone:847-946-3842
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-31
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL096.0040562255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program