Basic Information
| Provider Information | |||||||||
| NPI: | 1154900181 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVENINGRED | ||||||||
| FirstName: | SHARON | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 48675 AMERICAN ELM DR | ||||||||
| Address2: | |||||||||
| City: | MACOMB | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480441429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862634910 | ||||||||
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| Practice Location | |||||||||
| Address1: | 16301 19 MILE RD | ||||||||
| Address2: | |||||||||
| City: | CLINTON TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480381104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862632480 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2021 | ||||||||
| LastUpdateDate: | 04/06/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 5502000027 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.