Provider Demographics
NPI:1184011306
Name:DEVEAU, BRIAN CHARLES (PTA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:CHARLES
Last Name:DEVEAU
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1904 PAR PL
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34240-9689
Mailing Address - Country:US
Mailing Address - Phone:941-929-3770
Mailing Address - Fax:
Practice Address - Street 1:1904 PAR PL
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34240-9689
Practice Address - Country:US
Practice Address - Phone:941-929-3770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-26
Last Update Date:2015-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL25200172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker