Provider Demographics
NPI:1700673522
Name:DEVORE, CARLEY SHAWN (LMT)
Entity type:Individual
Prefix:
First Name:CARLEY
Middle Name:SHAWN
Last Name:DEVORE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:CARLEY
Other - Middle Name:SHAWN
Other - Last Name:PARTHREE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:POTLATCH
Mailing Address - State:ID
Mailing Address - Zip Code:83855-0247
Mailing Address - Country:US
Mailing Address - Phone:509-378-1000
Mailing Address - Fax:
Practice Address - Street 1:102 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-2842
Practice Address - Country:US
Practice Address - Phone:208-882-3012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-23
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID4771555225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist