Provider Demographics
NPI:1417153875
Name:KEOUGH, EVYL LYNN (RPT)
Entity Type:Individual
Prefix:MRS
First Name:EVYL
Middle Name:LYNN
Last Name:KEOUGH
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:MRS
Other - First Name:EVYL
Other - Middle Name:LYNN
Other - Last Name:WISE-KEOUGH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:172 BROWNS RIVER RD
Mailing Address - Street 2:
Mailing Address - City:ESSEX JUNCTION
Mailing Address - State:VT
Mailing Address - Zip Code:05452-2220
Mailing Address - Country:US
Mailing Address - Phone:802-872-8202
Mailing Address - Fax:802-872-5879
Practice Address - Street 1:25 BISHOP AVE
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-7871
Practice Address - Country:US
Practice Address - Phone:802-878-8330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VTPT18702225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist