Provider Demographics
NPI:1508131137
Name:MERGENDAHL, SALLY B (OT)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:B
Last Name:MERGENDAHL
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:B
Other - Last Name:BULMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5412 US HIGHWAY 10 E
Mailing Address - Street 2:
Mailing Address - City:STEVENS POINT
Mailing Address - State:WI
Mailing Address - Zip Code:54482-8559
Mailing Address - Country:US
Mailing Address - Phone:715-346-5243
Mailing Address - Fax:
Practice Address - Street 1:5412 US HIGHWAY 10 E
Practice Address - Street 2:
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54482-8559
Practice Address - Country:US
Practice Address - Phone:715-346-5243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-15
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI417-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI417-26OtherWI STATE LIC