Provider Demographics
NPI:1720189103
Name:EAVENSON, TERRY ANN (LMRT)
Entity Type:Individual
Prefix:MS
First Name:TERRY
Middle Name:ANN
Last Name:EAVENSON
Suffix:
Gender:F
Credentials:LMRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11529 AMBERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:TX
Mailing Address - Zip Code:77356
Mailing Address - Country:US
Mailing Address - Phone:936-827-8410
Mailing Address - Fax:
Practice Address - Street 1:3115 COLLEGE PARK DR
Practice Address - Street 2:STE 104
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77384-4009
Practice Address - Country:US
Practice Address - Phone:936-321-5030
Practice Address - Fax:936-271-5033
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX200572247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist