Provider Demographics
NPI:1639125180
Name:BURTIS, EVELYNE VANITHA (MSPT)
Entity Type:Individual
Prefix:
First Name:EVELYNE
Middle Name:VANITHA
Last Name:BURTIS
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:EVELYNE
Other - Middle Name:VANITHA
Other - Last Name:DANIEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:1467 N MACK SMITH RD
Practice Address - Street 2:
Practice Address - City:EAST RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37412-3947
Practice Address - Country:US
Practice Address - Phone:423-894-4403
Practice Address - Fax:423-894-4513
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3156797OtherBCBST - GROUP NUMBER
TN5441369Medicaid
TN5441369Medicaid
TN446652Medicare ID - Type UnspecifiedGROUP NUMBER