Provider Demographics
NPI:1164778486
Name:SOUBLIERE, SARABETH RUTH (MSED, ITDS)
Entity type:Individual
Prefix:MRS
First Name:SARABETH
Middle Name:RUTH
Last Name:SOUBLIERE
Suffix:
Gender:F
Credentials:MSED, ITDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 GEORGETOWNE BLVD # A
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32119-8902
Mailing Address - Country:US
Mailing Address - Phone:386-631-3067
Mailing Address - Fax:
Practice Address - Street 1:236 GEORGETOWNE BLVD
Practice Address - Street 2:N/A
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32119
Practice Address - Country:US
Practice Address - Phone:386-631-3067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-24
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
252Y00000X, 101YM0800X
FL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No252Y00000XAgenciesEarly Intervention Provider Agency
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015103300Medicaid