Provider Demographics
NPI:1578697405
Name:EVANS, TERRESSA YAVONNE (LMT)
Entity Type:Individual
Prefix:MS
First Name:TERRESSA
Middle Name:YAVONNE
Last Name:EVANS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 405
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSON
Mailing Address - State:WV
Mailing Address - Zip Code:25661
Mailing Address - Country:US
Mailing Address - Phone:304-235-1444
Mailing Address - Fax:304-235-1444
Practice Address - Street 1:411 VICTORIA STREET
Practice Address - Street 2:
Practice Address - City:WILLIAMSON
Practice Address - State:WV
Practice Address - Zip Code:25661
Practice Address - Country:US
Practice Address - Phone:304-235-1444
Practice Address - Fax:304-235-1444
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2009-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2006-225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist