Healthcare Provider Details

I. General information

NPI: 1083744593
Provider Name (Legal Business Name): MINDY S DEPUE ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4444 NW HIGHLAND DR
CORVALLIS OR
97330-9734
US

IV. Provider business mailing address

2491 WATERFORD ST SE
ALBANY OR
97322-8818
US

V. Phone/Fax

Practice location:
  • Phone: 541-766-4909
  • Fax:
Mailing address:
  • Phone: 541-990-2388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT-AT-1007419
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: