Provider Demographics
NPI:1477688950
Name:EVANS, THERESA M (COTA)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:M
Last Name:EVANS
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:431 LOFTON RD
Mailing Address - Street 2:
Mailing Address - City:RAPHINE
Mailing Address - State:VA
Mailing Address - Zip Code:24472-2821
Mailing Address - Country:US
Mailing Address - Phone:540-457-1219
Mailing Address - Fax:
Practice Address - Street 1:431 LOFTON RD
Practice Address - Street 2:
Practice Address - City:RAPHINE
Practice Address - State:VA
Practice Address - Zip Code:24472-2821
Practice Address - Country:US
Practice Address - Phone:540-457-1219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131000210224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA496665Medicare Oscar/Certification