Provider Demographics
NPI:1790707768
Name:HUIZENGA, SARA RENEA (PT)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:RENEA
Last Name:HUIZENGA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:R
Other - Last Name:HUIZENGA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1849 MANN ST
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-3484
Mailing Address - Country:US
Mailing Address - Phone:630-291-3699
Mailing Address - Fax:
Practice Address - Street 1:1704 LENA ST STE A1
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-2002
Practice Address - Country:US
Practice Address - Phone:505-471-0818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2009-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2812225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM55422373Medicaid
NMNM00Q286OtherBLUE CROSS BLUE SHIELD NM
NMNM00Q286OtherBLUE CROSS BLUE SHIELD NM