Provider Demographics
NPI:1760663918
Name:DEAVER, KIM (ATC)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:DEAVER
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1235 OVERLOOK DR
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97034-6945
Mailing Address - Country:US
Mailing Address - Phone:503-534-2407
Mailing Address - Fax:
Practice Address - Street 1:1235 OVERLOOK DR
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97034-6945
Practice Address - Country:US
Practice Address - Phone:503-534-2407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORATAT10079322255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORATAT1007932OtherOHLA