Provider Demographics
NPI:1538458120
Name:DODGE, DEVYN R (DPT)
Entity Type:Individual
Prefix:
First Name:DEVYN
Middle Name:R
Last Name:DODGE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12072 W MCMILLAN RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-2462
Mailing Address - Country:US
Mailing Address - Phone:208-939-0533
Mailing Address - Fax:
Practice Address - Street 1:805 W PALMDALE BLVD
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93551-4251
Practice Address - Country:US
Practice Address - Phone:661-947-9977
Practice Address - Fax:661-947-9988
Is Sole Proprietor?:No
Enumeration Date:2011-04-04
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT37525225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist