Provider Demographics
NPI:1366578106
Name:DAHL, COREY SHANE (PT, MPT, OCS)
Entity type:Individual
Prefix:MR
First Name:COREY
Middle Name:SHANE
Last Name:DAHL
Suffix:
Gender:M
Credentials:PT, MPT, OCS
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 128
Mailing Address - Street 2:PHS INDIAN HEALTH CENTER ATTN: PHYSICAL THERAPY DEPT.
Mailing Address - City:FORT WASHAKIE
Mailing Address - State:WY
Mailing Address - Zip Code:82514
Mailing Address - Country:US
Mailing Address - Phone:307-335-5935
Mailing Address - Fax:
Practice Address - Street 1:29 BLACK COAL DRIVE
Practice Address - Street 2:PHS INDIAN HEALTH CENTER ATTN: PHYSICAL THERAPY DEPT.
Practice Address - City:FORT WASHAKIE
Practice Address - State:WY
Practice Address - Zip Code:82514
Practice Address - Country:US
Practice Address - Phone:307-335-5935
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1116838225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist