Provider Demographics
NPI:1457658916
Name:EVANS, DEREK WELLER (CMT)
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:WELLER
Last Name:EVANS
Suffix:
Gender:M
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2282
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80150-2282
Mailing Address - Country:US
Mailing Address - Phone:406-599-9145
Mailing Address - Fax:
Practice Address - Street 1:8955 RIDGELINE BLVD
Practice Address - Street 2:SUITE 500
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80129-2362
Practice Address - Country:US
Practice Address - Phone:720-488-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-18
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO11436225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist