Provider Demographics
NPI:1295203149
Name:CHRISTY, SALLY ANN
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:ANN
Last Name:CHRISTY
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 1234
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-0100
Mailing Address - Country:US
Mailing Address - Phone:206-715-1879
Mailing Address - Fax:
Practice Address - Street 1:569 NE HARRISON ST
Practice Address - Street 2:
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-8403
Practice Address - Country:US
Practice Address - Phone:206-715-1879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-08
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA161339G235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA161339GMedicaid