Provider Demographics
NPI:1871553388
Name:REED, MARK ALLEN (MPT)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALLEN
Last Name:REED
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 12TH AVE S
Mailing Address - Street 2:STE 105
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651
Mailing Address - Country:US
Mailing Address - Phone:208-467-4357
Mailing Address - Fax:208-467-4395
Practice Address - Street 1:1015 12TH AVE S
Practice Address - Street 2:STE 105
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651
Practice Address - Country:US
Practice Address - Phone:208-467-4357
Practice Address - Fax:208-467-4395
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT854225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TC548OtherBLUE CROSS OF ID
000010150640OtherBLUE SHIELD OF ID
000010150640OtherBLUE SHIELD OF ID