Provider Demographics
NPI:1194822528
Name:DECLOSS, LINDSEY E (MSPT)
Entity Type:Individual
Prefix:
First Name:LINDSEY
Middle Name:E
Last Name:DECLOSS
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 E SAN PEDRO ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-5650
Mailing Address - Country:US
Mailing Address - Phone:208-991-8608
Mailing Address - Fax:
Practice Address - Street 1:9652 W STATE ST
Practice Address - Street 2:
Practice Address - City:STAR
Practice Address - State:ID
Practice Address - Zip Code:83669-5858
Practice Address - Country:US
Practice Address - Phone:208-286-0766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID2387225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT323070Medicare PIN