Provider Demographics
NPI:1215237037
Name:EVANS, MARY E (COTA/L)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:EVANS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1004
Mailing Address - Street 2:
Mailing Address - City:JOHNSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29555-1004
Mailing Address - Country:US
Mailing Address - Phone:843-472-9752
Mailing Address - Fax:
Practice Address - Street 1:121 E CEDAR ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2576
Practice Address - Country:US
Practice Address - Phone:843-661-3426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-26
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2857224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant