Provider Demographics
NPI:1427596915
Name:EVANS, THERESA MAE
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:MAE
Last Name:EVANS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:M
Other - Last Name:EVANS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:COTA/L
Mailing Address - Street 1:PO BOX 195
Mailing Address - Street 2:303 N LEE
Mailing Address - City:LEETON
Mailing Address - State:MO
Mailing Address - Zip Code:64761
Mailing Address - Country:US
Mailing Address - Phone:660-221-4281
Mailing Address - Fax:
Practice Address - Street 1:303 N LEE
Practice Address - Street 2:
Practice Address - City:LEETON
Practice Address - State:MO
Practice Address - Zip Code:64761
Practice Address - Country:US
Practice Address - Phone:660-221-4281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-06
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012001563224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant