Provider Demographics
NPI:1619543246
Name:HUDDLESTON, DEVERY BRIANNE (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:DEVERY
Middle Name:BRIANNE
Last Name:HUDDLESTON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:DEVERY
Other - Middle Name:
Other - Last Name:GALLEGOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:808 CLARION DR
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82718-7581
Mailing Address - Country:US
Mailing Address - Phone:707-815-6907
Mailing Address - Fax:
Practice Address - Street 1:1103 E BOXELDER RD STE U
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82718-5582
Practice Address - Country:US
Practice Address - Phone:307-686-8177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-03
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT-2072225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYPT-2072Medicaid