Provider Demographics
NPI:1699216002
Name:SPACKMAN, EMILY (DPT)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:SPACKMAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 S 2ND W
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-2300
Mailing Address - Country:US
Mailing Address - Phone:208-356-0220
Mailing Address - Fax:
Practice Address - Street 1:660 S 2ND W
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2300
Practice Address - Country:US
Practice Address - Phone:208-356-0220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-17
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID4984225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist