Provider Demographics
NPI:1508834623
Name:SUNDERLAND, SCOTT WILLIAM (MS, ATC)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:WILLIAM
Last Name:SUNDERLAND
Suffix:
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 CHESTNUT CT
Mailing Address - Street 2:
Mailing Address - City:DAHINDA
Mailing Address - State:IL
Mailing Address - Zip Code:61428-9732
Mailing Address - Country:US
Mailing Address - Phone:309-879-2892
Mailing Address - Fax:
Practice Address - Street 1:2 E SOUTH ST
Practice Address - Street 2:K-226
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-4986
Practice Address - Country:US
Practice Address - Phone:309-341-7378
Practice Address - Fax:309-341-7091
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer