Provider Demographics
NPI:1851168678
Name:EAVENSON, KELLEY LEIGH (PTA)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:LEIGH
Last Name:EAVENSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4460 SEBEWAING RD
Mailing Address - Street 2:
Mailing Address - City:OWENDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48754-9797
Mailing Address - Country:US
Mailing Address - Phone:706-680-8655
Mailing Address - Fax:
Practice Address - Street 1:1167 E HOPSON ST
Practice Address - Street 2:
Practice Address - City:BAD AXE
Practice Address - State:MI
Practice Address - Zip Code:48413-1555
Practice Address - Country:US
Practice Address - Phone:989-269-9983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-11
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502007923225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant