Provider Demographics
NPI:1831549401
Name:EVANS, TRISHA (MOT)
Entity type:Individual
Prefix:
First Name:TRISHA
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:TRISHA
Other - Middle Name:A
Other - Last Name:MILES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MOT
Mailing Address - Street 1:1216 HOLMAN AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2907
Mailing Address - Country:US
Mailing Address - Phone:208-319-4187
Mailing Address - Fax:
Practice Address - Street 1:36 PROFESSIONAL PLAZA
Practice Address - Street 2:SUITE 110
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440
Practice Address - Country:US
Practice Address - Phone:208-359-9570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-15
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOTL-1612225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist