Provider Demographics
NPI:1629404538
Name:IDNAY, DEXTER (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:DEXTER
Middle Name:
Last Name:IDNAY
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:HARBOR BEACH
Mailing Address - State:MI
Mailing Address - Zip Code:48441-1101
Mailing Address - Country:US
Mailing Address - Phone:989-479-3101
Mailing Address - Fax:989-479-3529
Practice Address - Street 1:129 N 1ST ST
Practice Address - Street 2:
Practice Address - City:HARBOR BEACH
Practice Address - State:MI
Practice Address - Zip Code:48441-1102
Practice Address - Country:US
Practice Address - Phone:989-479-3101
Practice Address - Fax:989-479-3529
Is Sole Proprietor?:No
Enumeration Date:2013-09-24
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501013852225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist