Provider Demographics
NPI:1164635181
Name:FISHER, SALLY (PT)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:FISHER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2540 CARMICHAEL WAY
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-5314
Mailing Address - Country:US
Mailing Address - Phone:916-482-0465
Mailing Address - Fax:916-487-8623
Practice Address - Street 1:2540 CARMICHAEL WAY
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-5314
Practice Address - Country:US
Practice Address - Phone:916-482-0465
Practice Address - Fax:916-487-8623
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 12954225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT 12954OtherLICENSE NUMBER
CA0PT129540Medicare ID - Type UnspecifiedPROVIDER NUMBER