Provider Demographics
NPI:1346987278
Name:EVANS, MELISSA JANE
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:JANE
Last Name:EVANS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 168
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39059-0168
Mailing Address - Country:US
Mailing Address - Phone:850-588-9641
Mailing Address - Fax:888-711-0441
Practice Address - Street 1:522 SIXTH BAXTER XING STE B
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-6634
Practice Address - Country:US
Practice Address - Phone:803-929-7408
Practice Address - Fax:888-711-0441
Is Sole Proprietor?:No
Enumeration Date:2022-05-12
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4760225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist