Provider Demographics
NPI:1255508917
Name:DEAVER, RICHARD J (PT)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:J
Last Name:DEAVER
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 1:7754 1 BRAEGER RD
Mailing Address - Street 2:
Mailing Address - City:THREE LAKES
Mailing Address - State:WI
Mailing Address - Zip Code:54562-9207
Mailing Address - Country:US
Mailing Address - Phone:715-546-8026
Mailing Address - Fax:
Practice Address - Street 1:7754 BRAEGER RD
Practice Address - Street 2:
Practice Address - City:THREE LAKES
Practice Address - State:WI
Practice Address - Zip Code:54562-9207
Practice Address - Country:US
Practice Address - Phone:715-546-8026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI963-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40100700Medicaid