Provider Demographics
NPI:1548399124
Name:POTEREK, SARAH (DT)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:POTEREK
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 NATIONS DR STE 208
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-9173
Mailing Address - Country:US
Mailing Address - Phone:847-477-9034
Mailing Address - Fax:847-623-8861
Practice Address - Street 1:1800 NATIONS DR STE 208
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-9173
Practice Address - Country:US
Practice Address - Phone:847-477-9034
Practice Address - Fax:847-623-8861
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2008-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04932271OtherBLUE SHIELD PROVIDER NUMB