Provider Demographics
NPI:1316102965
Name:EVANGELISTA, JANICE FAJARDO (OTR)
Entity type:Individual
Prefix:
First Name:JANICE
Middle Name:FAJARDO
Last Name:EVANGELISTA
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 E SUNSET PIKE DR
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-4574
Mailing Address - Country:US
Mailing Address - Phone:812-299-0278
Mailing Address - Fax:
Practice Address - Street 1:3500 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47804-1732
Practice Address - Country:US
Practice Address - Phone:812-238-6986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-23
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31003991A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist