Provider Demographics
NPI:1255512117
Name:DAVIS, DEVON E (PT, DPT)
Entity type:Individual
Prefix:
First Name:DEVON
Middle Name:E
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:DEVON
Other - Middle Name:
Other - Last Name:PEDERSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:PO BOX 1014
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066-1014
Mailing Address - Country:US
Mailing Address - Phone:732-855-9751
Mailing Address - Fax:732-855-9755
Practice Address - Street 1:62 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:WESTWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07675-2000
Practice Address - Country:US
Practice Address - Phone:201-664-1118
Practice Address - Fax:732-855-9755
Is Sole Proprietor?:No
Enumeration Date:2007-11-20
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01082900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ120414DBDOtherMEDICARE