Provider Demographics
NPI:1235826595
Name:DEVERS, IDAMAE
Entity Type:Individual
Prefix:
First Name:IDAMAE
Middle Name:
Last Name:DEVERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1209 GRANT AVE STE 2F
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-3706
Mailing Address - Country:US
Mailing Address - Phone:215-676-2104
Mailing Address - Fax:215-673-2701
Practice Address - Street 1:1209 GRANT AVE STE 2F
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-3706
Practice Address - Country:US
Practice Address - Phone:215-676-2104
Practice Address - Fax:215-673-2701
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA107249171400000X, 174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
No171400000XOther Service ProvidersHealth & Wellness Coach