Basic Information
| Provider Information | |||||||||
| NPI: | 1164635181 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FISHER | ||||||||
| FirstName: | SALLY | ||||||||
| MiddleName: | |||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2540 CARMICHAEL WAY | ||||||||
| Address2: | |||||||||
| City: | CARMICHAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956085314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164820465 | ||||||||
| FaxNumber: | 9164878623 | ||||||||
| Practice Location | |||||||||
| Address1: | 2540 CARMICHAEL WAY | ||||||||
| Address2: | |||||||||
| City: | CARMICHAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956085314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164820465 | ||||||||
| FaxNumber: | 9164878623 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2007 | ||||||||
| LastUpdateDate: | 04/01/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT 12954 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | PT 12954 | 01 | CA | LICENSE NUMBER | OTHER |