Provider Demographics
NPI:1326899113
Name:EVAK, KELLY (OTR/L)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:EVAK
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:RICHLAND CENTER
Mailing Address - State:WI
Mailing Address - Zip Code:53581-1914
Mailing Address - Country:US
Mailing Address - Phone:630-699-8683
Mailing Address - Fax:
Practice Address - Street 1:333 E 2ND ST
Practice Address - Street 2:
Practice Address - City:RICHLAND CENTER
Practice Address - State:WI
Practice Address - Zip Code:53581-1914
Practice Address - Country:US
Practice Address - Phone:608-647-6321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-29
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056014932225X00000X
FLOT23926225X00000X
TX123612225X00000X
AZOTH-009315225X00000X
WI7147225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist