Provider Demographics
NPI:1336113943
Name:REDISKE, SALLIE W (MPT)
Entity Type:Individual
Prefix:
First Name:SALLIE
Middle Name:W
Last Name:REDISKE
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4141 PENNOCK ST
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:AK
Mailing Address - Zip Code:99603-7223
Mailing Address - Country:US
Mailing Address - Phone:907-235-3410
Mailing Address - Fax:907-235-3417
Practice Address - Street 1:4141 PENNOCK ST
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603-7223
Practice Address - Country:US
Practice Address - Phone:907-235-3410
Practice Address - Fax:907-235-3417
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1134225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKK152880Medicare ID - Type UnspecifiedPROVIDER NUMBER