MEDICARE: ILISE DEVINE MEARS PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	3359	AZ
2	225100000X	Physical Therapist	PT00010344	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	86059251885711A007	OTHER	AZ	TRICARE

General Provider Information

NPI Number	:	1194722728
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ILISE DEVINE MEARS PT

Provider Business Mailing Address
First Line	:	10208 N DIVISION ST STE 102
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99218-1570
Country	:	US
Telephone Number	:	509-465-5400
Fax Number	:	509-465-5401

Provider Business Practice Location Address
First Line	:	10208 N DIVISION ST STE 102
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99218-1570
Country	:	US
Telephone Number	:	509-465-5400
Fax Number	:	509-465-5401

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/28/2005
Last Update Date	:	06/27/2019

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Directions to “ ILISE DEVINE MEARS PT” Practice Location

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