Provider Demographics
NPI:1578761508
Name:EVERSON, CHAD EDWARD (PTA)
Entity Type:Individual
Prefix:MR
First Name:CHAD
Middle Name:EDWARD
Last Name:EVERSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6291 COX ST
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-1561
Mailing Address - Country:US
Mailing Address - Phone:330-346-0496
Mailing Address - Fax:
Practice Address - Street 1:575 S CLEVELAND MASSILLON RD
Practice Address - Street 2:THERAPY DEPT.
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333-3019
Practice Address - Country:US
Practice Address - Phone:330-666-5866
Practice Address - Fax:330-666-3215
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-11
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH04933225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0139424Medicaid