Provider Demographics
NPI:1548747355
Name:DEAVER, BRENDA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:DEAVER
Suffix:
Gender:F
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 1:9962 ROCKSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-4701
Mailing Address - Country:US
Mailing Address - Phone:801-244-5605
Mailing Address - Fax:
Practice Address - Street 1:2411 W HORIZON RIDGE PKWY STE 100
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-5780
Practice Address - Country:US
Practice Address - Phone:702-458-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3752225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist