Provider Demographics
NPI:1154979268
Name:CRIST, EVELYN M (LMT)
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:M
Last Name:CRIST
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51999 SW 4TH ST
Mailing Address - Street 2:
Mailing Address - City:SCAPPOOSE
Mailing Address - State:OR
Mailing Address - Zip Code:97056-3723
Mailing Address - Country:US
Mailing Address - Phone:503-961-5322
Mailing Address - Fax:503-543-6611
Practice Address - Street 1:52485 SW 1ST ST
Practice Address - Street 2:
Practice Address - City:SCAPPOOSE
Practice Address - State:OR
Practice Address - Zip Code:97056-3531
Practice Address - Country:US
Practice Address - Phone:503-961-5322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-01
Last Update Date:2019-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12278225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
12278OtherL.M.T. #