Provider Demographics
NPI:1326441361
Name:BERUBE, SANDRA SUE
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:SUE
Last Name:BERUBE
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 1:396 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04073-5226
Mailing Address - Country:US
Mailing Address - Phone:207-608-3198
Mailing Address - Fax:
Practice Address - Street 1:396 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:ME
Practice Address - Zip Code:04073-5226
Practice Address - Country:US
Practice Address - Phone:207-608-3198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-05
Last Update Date:2014-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME246RP1900X, 246Z00000X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other