Provider Demographics
NPI:1265448799
Name:EVANS, KELLI D (MSRPT)
Entity Type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:D
Last Name:EVANS
Suffix:
Gender:F
Credentials:MSRPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 BEAR CREEK CT
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-1377
Mailing Address - Country:US
Mailing Address - Phone:618-288-1336
Mailing Address - Fax:
Practice Address - Street 1:16 GINGER CREEK PKWY
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-3502
Practice Address - Country:US
Practice Address - Phone:618-656-1122
Practice Address - Fax:618-656-1171
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist