Provider Demographics
NPI:1558035600
Name:EVANS, ROSALIE ANN (THW000104574)
Entity Type:Individual
Prefix:
First Name:ROSALIE
Middle Name:ANN
Last Name:EVANS
Suffix:
Gender:F
Credentials:THW000104574
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 LYON ST SE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321-2707
Mailing Address - Country:US
Mailing Address - Phone:541-791-3411
Mailing Address - Fax:
Practice Address - Street 1:231 LYON ST SE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-2707
Practice Address - Country:US
Practice Address - Phone:541-791-3411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR104574175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist