Provider Demographics
NPI:1407307705
Name:EVANS, ELISE (OT)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2331 EAST JOLLY RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910
Mailing Address - Country:US
Mailing Address - Phone:517-272-5133
Mailing Address - Fax:517-272-5138
Practice Address - Street 1:2331 EAST JOLLY RD
Practice Address - Street 2:SUITE B
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910
Practice Address - Country:US
Practice Address - Phone:517-272-5133
Practice Address - Fax:517-272-5138
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-21
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201009561225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist