Basic Information
| Provider Information | |||||||||
| NPI: | 1831549401 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | TRISHA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MOT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MILES | ||||||||
| OtherFirstName: | TRISHA | ||||||||
| OtherMiddleName: | A | ||||||||
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| OtherCredential: | MOT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1216 HOLMAN AVE | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832012907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083194187 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 36 PROFESSIONAL PLAZA | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | REXBURG | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083599570 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2016 | ||||||||
| LastUpdateDate: | 06/15/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OTL-1612 | ID | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.