Provider Demographics
NPI:1659449551
Name:DEVEREAUX, KERRY (MSPT, CLT)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:DEVEREAUX
Suffix:
Gender:F
Credentials:MSPT, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1383 SARANDON DR
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28104-6864
Mailing Address - Country:US
Mailing Address - Phone:704-778-6338
Mailing Address - Fax:
Practice Address - Street 1:1383 SARANDON DR
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28104-6864
Practice Address - Country:US
Practice Address - Phone:704-778-6338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11530225100000X
SC5689225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7212470Medicaid