Provider Demographics
NPI:1457785107
Name:WEVODAU, EMILY (PTA)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:WEVODAU
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5707 N VILLA CIR
Mailing Address - Street 2:#787
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-7293
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1485 N TURQUOISE DR
Practice Address - Street 2:SUITE 220
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1398
Practice Address - Country:US
Practice Address - Phone:928-774-6626
Practice Address - Fax:928-214-3277
Is Sole Proprietor?:No
Enumeration Date:2013-08-29
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10346APTA225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant