Provider Demographics
NPI:1073999702
Name:EVANS, KRISTINE
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2813 MILLER RD
Mailing Address - Street 2:
Mailing Address - City:MARENGO
Mailing Address - State:IL
Mailing Address - Zip Code:60152-9245
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2813 MILLER RD
Practice Address - Street 2:
Practice Address - City:MARENGO
Practice Address - State:IL
Practice Address - Zip Code:60152-9245
Practice Address - Country:US
Practice Address - Phone:847-507-9205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-05
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No174400000XOther Service ProvidersSpecialist