Provider Demographics
NPI:1083766281
Name:EVANS, MARY BETH
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:BETH
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:PO BOX 3276
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47731-3276
Mailing Address - Country:US
Mailing Address - Phone:812-473-0181
Mailing Address - Fax:812-473-5822
Practice Address - Street 1:1169 EASTERN PKWY
Practice Address - Street 2:SUITE 2313
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1417
Practice Address - Country:US
Practice Address - Phone:502-309-9800
Practice Address - Fax:502-309-9797
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY001579225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000964014OtherANTHEM BCBS
KY87015798Medicaid
KY001579OtherLICENSE
002124OtherCERTIFICATION - LYMPHOLOGY ASSOCIATION OF NORTH AMERICA
002124OtherCERTIFICATION - LYMPHOLOGY ASSOCIATION OF NORTH AMERICA