Basic Information
| Provider Information | |||||||||
| NPI: | 1346987278 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | JANE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 168 | ||||||||
| Address2: | |||||||||
| City: | CRYSTAL SPRINGS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390590168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8505889641 | ||||||||
| FaxNumber: | 8887110441 | ||||||||
| Practice Location | |||||||||
| Address1: | 522 SIXTH BAXTER XING STE B | ||||||||
| Address2: | |||||||||
| City: | FORT MILL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297086634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8039297408 | ||||||||
| FaxNumber: | 8887110441 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2022 | ||||||||
| LastUpdateDate: | 05/12/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 4760 | SC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.