Provider Demographics
NPI:1164283198
Name:EVANS, MYKI L (LMT)
Entity Type:Individual
Prefix:
First Name:MYKI
Middle Name:L
Last Name:EVANS
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 1:265 COLORADO AVE APT C4
Mailing Address - Street 2:
Mailing Address - City:WHITEFISH
Mailing Address - State:MT
Mailing Address - Zip Code:59937-2478
Mailing Address - Country:US
Mailing Address - Phone:406-941-3911
Mailing Address - Fax:
Practice Address - Street 1:505 SPOKANE AVE
Practice Address - Street 2:
Practice Address - City:WHITEFISH
Practice Address - State:MT
Practice Address - Zip Code:59937-2780
Practice Address - Country:US
Practice Address - Phone:406-862-1071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTLMT-LMT-LIC-24865225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist