Provider Demographics
NPI:1790530590
Name:COLE, DAVEDA (LMT)
Entity type:Individual
Prefix:MISS
First Name:DAVEDA
Middle Name:
Last Name:COLE
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 1:7789 W BELL RD STE 102
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-3802
Mailing Address - Country:US
Mailing Address - Phone:623-412-7877
Mailing Address - Fax:623-979-8049
Practice Address - Street 1:7789 W BELL RD STE 102
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-3802
Practice Address - Country:US
Practice Address - Phone:623-412-7877
Practice Address - Fax:623-979-8049
Is Sole Proprietor?:No
Enumeration Date:2024-04-23
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-25812225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist