Provider Demographics
NPI:1154169274
Name:EVANGELISTA, FAYE (OTR/L)
Entity type:Individual
Prefix:
First Name:FAYE
Middle Name:
Last Name:EVANGELISTA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16339 E BRIDGER ST
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91722-3303
Mailing Address - Country:US
Mailing Address - Phone:626-343-6165
Mailing Address - Fax:
Practice Address - Street 1:301 E FOOTHILL BLVD STE 100
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91006-2551
Practice Address - Country:US
Practice Address - Phone:833-319-3969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-15
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26526225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist