Provider Demographics
NPI:1790729952
Name:SUNDAHL, BRIAN T (DPT)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:T
Last Name:SUNDAHL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:372 SOUTH BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ESTACADA
Mailing Address - State:OR
Mailing Address - Zip Code:97023
Mailing Address - Country:US
Mailing Address - Phone:503-630-5314
Mailing Address - Fax:503-630-5315
Practice Address - Street 1:19856 SE HIGHWAY 212
Practice Address - Street 2:
Practice Address - City:DAMASCUS
Practice Address - State:OR
Practice Address - Zip Code:97089-5743
Practice Address - Country:US
Practice Address - Phone:417-559-2627
Practice Address - Fax:503-386-2745
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00008548225100000X
OR5367225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5743SUOtherREGENCE BLUESHIELD
WA151355OtherLABOR & INDUSTRIES
WA8347015Medicaid
WA8930584OtherL&I CRIME VICTIMS PROGRAM
WAAB24078Medicare ID - Type Unspecified