Provider Demographics
NPI:1265982391
Name:DIRR, DAVONIA CAROLANN (LMT)
Entity type:Individual
Prefix:MRS
First Name:DAVONIA
Middle Name:CAROLANN
Last Name:DIRR
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 VANTROBA DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60139-2710
Mailing Address - Country:US
Mailing Address - Phone:630-290-0141
Mailing Address - Fax:
Practice Address - Street 1:640 E SAINT CHARLES RD
Practice Address - Street 2:104
Practice Address - City:CAROL STREAM
Practice Address - State:IL
Practice Address - Zip Code:60188-3083
Practice Address - Country:US
Practice Address - Phone:630-460-3431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-13
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.010208225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist