Provider Demographics
NPI:1497198188
Name:GAMBLE, DEVERE KEEN (MT)
Entity Type:Individual
Prefix:
First Name:DEVERE
Middle Name:KEEN
Last Name:GAMBLE
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 E 2ND AVE
Mailing Address - Street 2:SUITE 2C
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-5498
Mailing Address - Country:US
Mailing Address - Phone:970-946-1051
Mailing Address - Fax:
Practice Address - Street 1:755 E 2ND AVE
Practice Address - Street 2:SUITE 2C
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-5498
Practice Address - Country:US
Practice Address - Phone:970-946-1051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-11
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3709225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO3709OtherSTATE LICENSE