Provider Demographics
NPI:1093277659
Name:EVANGELISTA, FOTI (ATC, CAT(C), AT)
Entity Type:Individual
Prefix:MR
First Name:FOTI
Middle Name:
Last Name:EVANGELISTA
Suffix:
Gender:M
Credentials:ATC, CAT(C), AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:691 PIERRE STREET
Mailing Address - Street 2:
Mailing Address - City:LAVAL
Mailing Address - State:QUEBEC
Mailing Address - Zip Code:H7X3P4
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2801 W. BANCROFT ST.
Practice Address - Street 2:HEALTH AND HUMAN SERVICES RM 2505L, MAIL STOP 119
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-3390
Practice Address - Country:US
Practice Address - Phone:419-530-4241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-03
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT0060152255A2300X
ZZ2-55362255A2300X
20000344602255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer