Provider Demographics
NPI:1255756409
Name:DEVRIES, AUTUMN (LMT)
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:DEVRIES
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:796B ROGERS WAY
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-2687
Mailing Address - Country:US
Mailing Address - Phone:406-579-9967
Mailing Address - Fax:
Practice Address - Street 1:796B ROGERS WAY
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-2687
Practice Address - Country:US
Practice Address - Phone:406-579-9967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-25
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT363225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist