Provider Demographics
NPI:1083742597
Name:EVENSON, GABRIEL T (MOTRL)
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:T
Last Name:EVENSON
Suffix:
Gender:M
Credentials:MOTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4425 47TH ST. S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104
Mailing Address - Country:US
Mailing Address - Phone:701-200-8181
Mailing Address - Fax:
Practice Address - Street 1:3321 4TH AVE. S
Practice Address - Street 2:SUITE D
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103
Practice Address - Country:US
Practice Address - Phone:701-200-8181
Practice Address - Fax:701-365-8585
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND995225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND27813OtherBLUE CROSS BLUE SHIELD OF
ND27813OtherBLUE CROSS BLUE SHIELD OF