Provider Demographics
NPI:1548740624
Name:DAVENPORT, MEGGI (PT)
Entity type:Individual
Prefix:
First Name:MEGGI
Middle Name:
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2065 W RIVERSTONE DR STE 101
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-5699
Mailing Address - Country:US
Mailing Address - Phone:208-667-1988
Mailing Address - Fax:
Practice Address - Street 1:609 N CALGARY CT STE 2
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-4906
Practice Address - Country:US
Practice Address - Phone:208-457-3435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-17
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60872085225100000X
IDPT-84922251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1548740624Medicaid