Provider Demographics
NPI:1407307705
Name:EVANS, ELISE (OTRL)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5041 WILLOUGHBY RD APT 1
Mailing Address - Street 2:
Mailing Address - City:HOLT
Mailing Address - State:MI
Mailing Address - Zip Code:48842-1009
Mailing Address - Country:US
Mailing Address - Phone:517-648-5528
Mailing Address - Fax:
Practice Address - Street 1:2450 DELHI COMMERCE DR STE 5
Practice Address - Street 2:
Practice Address - City:HOLT
Practice Address - State:MI
Practice Address - Zip Code:48842-2193
Practice Address - Country:US
Practice Address - Phone:517-648-5528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-21
Last Update Date:2025-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201009561225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist