Provider Demographics
NPI:1396962437
Name:SANDRY, WILLIE GUY (PT)
Entity type:Individual
Prefix:MR
First Name:WILLIE
Middle Name:GUY
Last Name:SANDRY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 NE 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:CAMAS
Mailing Address - State:WA
Mailing Address - Zip Code:98607-2154
Mailing Address - Country:US
Mailing Address - Phone:360-834-7760
Mailing Address - Fax:503-557-4871
Practice Address - Street 1:414 NE 3RD AVE
Practice Address - Street 2:
Practice Address - City:CAMAS
Practice Address - State:WA
Practice Address - Zip Code:98607-2154
Practice Address - Country:US
Practice Address - Phone:360-834-7760
Practice Address - Fax:503-557-4871
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00008543225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7111628Medicaid
WA7111628Medicaid