Provider Demographics
NPI:1609919182
Name:EGAN, SALLY SUSAN (ATC, LAT, CSCS)
Entity Type:Individual
Prefix:MRS
First Name:SALLY
Middle Name:SUSAN
Last Name:EGAN
Suffix:
Gender:F
Credentials:ATC, LAT, CSCS
Other - Prefix:MS
Other - First Name:SALLY
Other - Middle Name:SUSAN
Other - Last Name:BUCKETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC, LAT, CSCS
Mailing Address - Street 1:W12529 ZIMDARS RD
Mailing Address - Street 2:
Mailing Address - City:LEOPOLIS
Mailing Address - State:WI
Mailing Address - Zip Code:54948-9732
Mailing Address - Country:US
Mailing Address - Phone:715-853-3565
Mailing Address - Fax:
Practice Address - Street 1:100 CTY RD B
Practice Address - Street 2:THERAPY SERVICES
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-7072
Practice Address - Country:US
Practice Address - Phone:715-526-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2015-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer