Provider Demographics
NPI:1235707001
Name:DUBOIS, SARANDON
Entity Type:Individual
Prefix:
First Name:SARANDON
Middle Name:
Last Name:DUBOIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:719 DEVON DR
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:61548-9460
Mailing Address - Country:US
Mailing Address - Phone:309-383-2970
Mailing Address - Fax:
Practice Address - Street 1:719 DEVON DR
Practice Address - Street 2:
Practice Address - City:GERMANTOWN HILLS
Practice Address - State:IL
Practice Address - Zip Code:61548-9460
Practice Address - Country:US
Practice Address - Phone:309-383-2970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA30967225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant