Provider Demographics
NPI:1427191303
Name:PAGE, EVAN BARTLETT (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:BARTLETT
Last Name:PAGE
Suffix:
Gender:M
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:435 PHALEN BLVD
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55130-5302
Practice Address - Country:US
Practice Address - Phone:651-295-6747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6405235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist