Provider Demographics
NPI:1558877662
Name:DEVORE, MERCEDES L
Entity Type:Individual
Prefix:
First Name:MERCEDES
Middle Name:L
Last Name:DEVORE
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 1:6047 S SCHAUPPSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:WOOD RIVER
Mailing Address - State:NE
Mailing Address - Zip Code:68883-9457
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1401 EAST ST, WOOD RIVER, NE 68883
Practice Address - Street 2:
Practice Address - City:WOOD RIVER
Practice Address - State:NE
Practice Address - Zip Code:68883
Practice Address - Country:US
Practice Address - Phone:308-583-2213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE972224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant