Provider Demographics
NPI:1477578482
Name:EVANS, KENT WILLIAM (ATC/L)
Entity Type:Individual
Prefix:MR
First Name:KENT
Middle Name:WILLIAM
Last Name:EVANS
Suffix:
Gender:M
Credentials:ATC/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8130 FENDLER DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46259-9793
Mailing Address - Country:US
Mailing Address - Phone:317-862-5072
Mailing Address - Fax:
Practice Address - Street 1:6215 S FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46259-9600
Practice Address - Country:US
Practice Address - Phone:317-803-5676
Practice Address - Fax:317-862-7262
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36000112A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer