Provider Demographics
NPI:1942281183
Name:DEVENPORT, BRENDA J (PT)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:J
Last Name:DEVENPORT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1397 S CANFIELD NILES RD
Mailing Address - Street 2:UNIT 1
Mailing Address - City:AUSTINTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44515-4084
Mailing Address - Country:US
Mailing Address - Phone:330-953-0129
Mailing Address - Fax:330-953-0650
Practice Address - Street 1:1397 S CANFIELD NILES RD
Practice Address - Street 2:UNIT 1
Practice Address - City:AUSTINTOWN
Practice Address - State:OH
Practice Address - Zip Code:44515-4084
Practice Address - Country:US
Practice Address - Phone:330-953-0129
Practice Address - Fax:330-953-0650
Is Sole Proprietor?:No
Enumeration Date:2005-11-05
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03968225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2361671Medicaid
OH000000370465OtherANTHEM
OHDA4145763OtherMEDICARE RAILROAD
OHDA4145763Medicare ID - Type UnspecifiedMEDICARE