Provider Demographics
NPI:1891098224
Name:DEVEAUX, BRIAN S (PT)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:S
Last Name:DEVEAUX
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563-2519
Mailing Address - Country:US
Mailing Address - Phone:516-599-8734
Mailing Address - Fax:516-599-5969
Practice Address - Street 1:44 BROADWAY
Practice Address - Street 2:
Practice Address - City:LYNBROOK
Practice Address - State:NY
Practice Address - Zip Code:11563
Practice Address - Country:US
Practice Address - Phone:516-599-8734
Practice Address - Fax:516-599-5969
Is Sole Proprietor?:No
Enumeration Date:2010-12-07
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033327174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY033327OtherLICENSE