Provider Demographics
NPI:1164800777
Name:WALLUS, EVIN RIDDLE (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:EVIN
Middle Name:RIDDLE
Last Name:WALLUS
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1299 103RD AVENUE
Mailing Address - Street 2:
Mailing Address - City:PLAINWELL
Mailing Address - State:MI
Mailing Address - Zip Code:49080
Mailing Address - Country:US
Mailing Address - Phone:269-598-7370
Mailing Address - Fax:
Practice Address - Street 1:1299 103RD AVENUE
Practice Address - Street 2:
Practice Address - City:PLAINWELL
Practice Address - State:MI
Practice Address - Zip Code:49080
Practice Address - Country:US
Practice Address - Phone:269-598-7370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-14
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15227225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist