Provider Demographics
NPI:1255678074
Name:DETWEILER, EVAN JAY (MBA, OT)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:JAY
Last Name:DETWEILER
Suffix:
Gender:M
Credentials:MBA, OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 SULLIVAN TRL
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18040-7958
Mailing Address - Country:US
Mailing Address - Phone:800-944-9782
Mailing Address - Fax:610-438-2046
Practice Address - Street 1:611 W COUNTY LINE RD S
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46814-7592
Practice Address - Country:US
Practice Address - Phone:260-625-1445
Practice Address - Fax:260-625-1445
Is Sole Proprietor?:No
Enumeration Date:2013-01-14
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31002343A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist