Provider Demographics
NPI:1336299411
Name:EVANS, MARY P (PTA, BS, LMP, CHP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:P
Last Name:EVANS
Suffix:
Gender:F
Credentials:PTA, BS, LMP, CHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16410 35TH AVENUE NE, STE 309
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98223
Mailing Address - Country:US
Mailing Address - Phone:360-658-9295
Mailing Address - Fax:360-658-5585
Practice Address - Street 1:16410 35TH AVENUE NE, STE 309
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98223
Practice Address - Country:US
Practice Address - Phone:360-658-9295
Practice Address - Fax:360-658-5585
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00008693225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAEV5316OtherREGENCE NUMBER
WA102665OtherL&I PROVIDER NUMBER