Provider Demographics
NPI:1790447167
Name:GILDEA, DEVON ROSS (MAT, AT, ATC)
Entity type:Individual
Prefix:
First Name:DEVON
Middle Name:ROSS
Last Name:GILDEA
Suffix:
Gender:M
Credentials:MAT, AT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:547 CHERRY ST SE APT 1N
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4749
Mailing Address - Country:US
Mailing Address - Phone:269-903-1794
Mailing Address - Fax:
Practice Address - Street 1:333 S CLARK ST
Practice Address - Street 2:
Practice Address - City:HOPKINS
Practice Address - State:MI
Practice Address - Zip Code:49328-9501
Practice Address - Country:US
Practice Address - Phone:269-793-7616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI26010026372255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer