Provider Demographics
NPI:1053534461
Name:DYE, JEREMY ALBERT (MPT)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:ALBERT
Last Name:DYE
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1917 N LAKEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2634
Mailing Address - Country:US
Mailing Address - Phone:208-664-8194
Mailing Address - Fax:208-667-1847
Practice Address - Street 1:1172 W HAYDEN AVE
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-8700
Practice Address - Country:US
Practice Address - Phone:208-773-8111
Practice Address - Fax:208-773-8385
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT2429225100000X
CAPT25530225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPT2429OtherBUREAU OF OCCUPATIONAL LICENSES