Provider Demographics
NPI:1720111826
Name:EVENSEN, KIRSTEN (OTR L)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:
Last Name:EVENSEN
Suffix:
Gender:F
Credentials:OTR L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1730
Mailing Address - Street 2:
Mailing Address - City:MCCALL
Mailing Address - State:ID
Mailing Address - Zip Code:83638-1730
Mailing Address - Country:US
Mailing Address - Phone:208-634-9788
Mailing Address - Fax:
Practice Address - Street 1:890 N COLE RD
Practice Address - Street 2:STE A
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8638
Practice Address - Country:US
Practice Address - Phone:208-323-8888
Practice Address - Fax:208-323-8889
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-500225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist