Provider Demographics
NPI:1477602431
Name:FULLER, SAGE MAETTA (MOT OTRL)
Entity Type:Individual
Prefix:MS
First Name:SAGE
Middle Name:MAETTA
Last Name:FULLER
Suffix:
Gender:F
Credentials:MOT OTRL
Other - Prefix:MRS
Other - First Name:SAGE
Other - Middle Name:MAETTA
Other - Last Name:BACZUK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MOT OTRL
Mailing Address - Street 1:PO BOX 1122
Mailing Address - Street 2:610 HIGH STREET
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045
Mailing Address - Country:US
Mailing Address - Phone:503-657-8903
Mailing Address - Fax:503-650-4302
Practice Address - Street 1:610 HIGH STREET
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045
Practice Address - Country:US
Practice Address - Phone:503-657-8903
Practice Address - Fax:503-650-4302
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR231089Medicaid
WA8397929Medicaid