Provider Demographics
NPI:1740748391
Name:LOTZ, EVAN WALTER (DPT)
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:WALTER
Last Name:LOTZ
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:908 W WILLIAM ST
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-4511
Mailing Address - Country:US
Mailing Address - Phone:217-722-1223
Mailing Address - Fax:
Practice Address - Street 1:18757 BURBANK BLVD STE 118
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-6345
Practice Address - Country:US
Practice Address - Phone:818-812-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-02
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
CA2959902251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist