Provider Demographics
NPI:1447708177
Name:DAVIS, BIRDEE LYNNE (PTA)
Entity type:Individual
Prefix:
First Name:BIRDEE
Middle Name:LYNNE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5646
Mailing Address - Country:US
Mailing Address - Phone:208-705-4999
Mailing Address - Fax:
Practice Address - Street 1:715 CHERRY ST
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5646
Practice Address - Country:US
Practice Address - Phone:208-705-4999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-11
Last Update Date:2016-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPTA-2547172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker