Provider Demographics
NPI:1962596908
Name:IVEY, KEVIN DALE (PT)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:DALE
Last Name:IVEY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:565 BRUNSWICK RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-9529
Mailing Address - Country:US
Mailing Address - Phone:530-273-4152
Mailing Address - Fax:530-273-4153
Practice Address - Street 1:565 BRUNSWICK RD
Practice Address - Street 2:SUITE 4
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-9529
Practice Address - Country:US
Practice Address - Phone:530-273-4152
Practice Address - Fax:530-273-4153
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA20829225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT208290Medicare ID - Type Unspecified