Provider Demographics
NPI:1033792023
Name:DAVOLT, DANIELLE M (PTA)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:M
Last Name:DAVOLT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:M
Other - Last Name:DAVOLT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3533 HIGHWAY 104 E
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-7611
Mailing Address - Country:US
Mailing Address - Phone:731-377-8407
Mailing Address - Fax:
Practice Address - Street 1:2036 US HIGHWAY 45 BYP S
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:TN
Practice Address - Zip Code:38382-2941
Practice Address - Country:US
Practice Address - Phone:731-377-8407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7500225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant