Provider Demographics
NPI:1477128916
Name:EVANS, MARIE THERESE (SLP)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:THERESE
Last Name:EVANS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1417 LAS VEGAS DR
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-5763
Mailing Address - Country:US
Mailing Address - Phone:734-717-4033
Mailing Address - Fax:
Practice Address - Street 1:10000 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-3330
Practice Address - Country:US
Practice Address - Phone:734-717-4033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101001702235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist