Provider Demographics
NPI:1407421126
Name:LOCKMER, BEAU STEPHEN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:BEAU
Middle Name:STEPHEN
Last Name:LOCKMER
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 E STATE ST STE 101
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-5915
Mailing Address - Country:US
Mailing Address - Phone:208-939-9594
Mailing Address - Fax:208-939-9828
Practice Address - Street 1:1673 W SHORELINE DR STE 230
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6752
Practice Address - Country:US
Practice Address - Phone:208-343-4700
Practice Address - Fax:208-343-4706
Is Sole Proprietor?:No
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-7235225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist