Provider Demographics
NPI:1376780486
Name:EVANS, LEAH MICHELLE
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:MICHELLE
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 1:1908 COUNTRY SQUARE RD
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:AR
Mailing Address - Zip Code:71730-9606
Mailing Address - Country:US
Mailing Address - Phone:870-866-0758
Mailing Address - Fax:
Practice Address - Street 1:200 W OAK ST
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:AR
Practice Address - Zip Code:71730-5618
Practice Address - Country:US
Practice Address - Phone:870-864-5006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-12
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A445224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant