Provider Demographics
NPI:1629107859
Name:DEVENPORT, GENIA LOUISE (MS PT)
Entity Type:Individual
Prefix:MS
First Name:GENIA
Middle Name:LOUISE
Last Name:DEVENPORT
Suffix:
Gender:F
Credentials:MS PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 E ORCHARD PARK RD
Mailing Address - Street 2:
Mailing Address - City:DEXTER
Mailing Address - State:NM
Mailing Address - Zip Code:88230-9704
Mailing Address - Country:US
Mailing Address - Phone:505-622-4905
Mailing Address - Fax:
Practice Address - Street 1:245 E ORCHARD PARK RD
Practice Address - Street 2:
Practice Address - City:DEXTER
Practice Address - State:NM
Practice Address - Zip Code:88230-9704
Practice Address - Country:US
Practice Address - Phone:505-622-4905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM396225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMT7398Medicaid