Provider Demographics
NPI:1770007122
Name:SAGAL, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SAGAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 438
Mailing Address - Street 2:
Mailing Address - City:SUTTON
Mailing Address - State:AK
Mailing Address - Zip Code:99674-0438
Mailing Address - Country:US
Mailing Address - Phone:907-982-2662
Mailing Address - Fax:
Practice Address - Street 1:400 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7018
Practice Address - Country:US
Practice Address - Phone:907-373-2022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-27
Last Update Date:2017-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK121990225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty