Provider Demographics
NPI:1104018449
Name:MUIR, SALLY M (DPT, OCS)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:M
Last Name:MUIR
Suffix:
Gender:F
Credentials:DPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:551 LONE PINE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-9403
Mailing Address - Country:US
Mailing Address - Phone:541-298-7202
Mailing Address - Fax:541-298-8008
Practice Address - Street 1:551 LONE PINE BLVD STE 103
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-9403
Practice Address - Country:US
Practice Address - Phone:541-298-7202
Practice Address - Fax:541-298-8008
Is Sole Proprietor?:No
Enumeration Date:2007-08-10
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6552061-2401225100000X
AK2364225100000X
OR600832251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKK152878Medicare PIN