Provider Demographics
NPI:1164778486
Name:SOUBLIERE, SARABETH RUTH (MSED, ITDS)
Entity Type:Individual
Prefix:MRS
First Name:SARABETH
Middle Name:RUTH
Last Name:SOUBLIERE
Suffix:
Gender:F
Credentials:MSED, ITDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:876 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32176-7851
Mailing Address - Country:US
Mailing Address - Phone:386-631-3067
Mailing Address - Fax:
Practice Address - Street 1:876 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32176-7851
Practice Address - Country:US
Practice Address - Phone:386-631-3067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-24
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101Y00000X, 222Q00000X
171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015103300Medicaid