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General NPI Number Information
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NPI Number | 1497142095
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Entity Type | Individual
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Provider Name | MARY DUDEVOIR
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Gender | Female
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Dates
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Enumeration Date | 04/21/2015
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Last Update Date | 04/21/2015
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Provider Practice Location Address
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Address Line | 12892 ROCKBRIDGE CIR
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City | COLORADO SPRINGS
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State | CO
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Zip | 80921-3743
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Country | US
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Telephone | 845-926-8707
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Fax |
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Provider Business Mailing Address
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Address Line | 12892 ROCKBRIDGE CIR
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City | COLORADO SPRINGS
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State | CO
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Zip | 80921-3743
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Country | US
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Telephone | 845-926-8707
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 1212
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License Number State | CO
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