Provider Demographics
NPI:1598279259
Name:BETTEY, EVAN JOHN (COTA/L)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:JOHN
Last Name:BETTEY
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1291 CRAIG AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-5704
Mailing Address - Country:US
Mailing Address - Phone:636-544-8557
Mailing Address - Fax:
Practice Address - Street 1:1291 CRAIG AVE
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-5704
Practice Address - Country:US
Practice Address - Phone:636-544-8557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-16
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant