Provider Demographics
NPI:1518366731
Name:DECOUTE, SANDRA
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:DECOUTE
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 1:93 MOONLIGHTWALK
Mailing Address - Street 2:93
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-4923
Mailing Address - Country:US
Mailing Address - Phone:631-258-8875
Mailing Address - Fax:
Practice Address - Street 1:93 MOONLIGHTWALK
Practice Address - Street 2:93
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-4923
Practice Address - Country:US
Practice Address - Phone:631-258-8875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY718545131174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist