Provider Demographics
NPI:1780081893
Name:DEVEREAUX, BRETT TYLER (ATC)
Entity type:Individual
Prefix:MR
First Name:BRETT
Middle Name:TYLER
Last Name:DEVEREAUX
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 N SAGINAW RD
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-3395
Mailing Address - Country:US
Mailing Address - Phone:517-936-9239
Mailing Address - Fax:
Practice Address - Street 1:4000 WHITING DR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-6634
Practice Address - Country:US
Practice Address - Phone:989-837-5894
Practice Address - Fax:989-837-4813
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-04
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL4807222255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer