Provider Demographics
NPI:1003912122
Name:MORRISON, GAVIN MCEACHERN (PT)
Entity Type:Individual
Prefix:
First Name:GAVIN
Middle Name:MCEACHERN
Last Name:MORRISON
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 1:4725 SAMARA ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-3642
Mailing Address - Country:US
Mailing Address - Phone:208-336-1042
Mailing Address - Fax:
Practice Address - Street 1:1101 N 28TH ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-2208
Practice Address - Country:US
Practice Address - Phone:208-336-1042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-1516225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist