Provider Demographics
NPI:1407286651
Name:WIBBENMEYER, SARAH
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:WIBBENMEYER
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 1:716 N WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:IL
Mailing Address - Zip Code:62450-2044
Mailing Address - Country:US
Mailing Address - Phone:618-838-5970
Mailing Address - Fax:
Practice Address - Street 1:360 SUMMIT ST
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:IL
Practice Address - Zip Code:62450-2028
Practice Address - Country:US
Practice Address - Phone:618-838-5970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-24
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
1-19-36840103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Multi-Specialty