Provider Demographics
NPI:1346685054
Name:DAHL, DANIELLE (AT, LMT)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:DAHL
Suffix:
Gender:F
Credentials:AT, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4138 S E ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97478-7595
Mailing Address - Country:US
Mailing Address - Phone:541-729-5277
Mailing Address - Fax:
Practice Address - Street 1:104 S PACIFIC HWY # 99
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:OR
Practice Address - Zip Code:97424-2100
Practice Address - Country:US
Practice Address - Phone:541-767-1616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-08
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10220174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist