Provider Demographics
NPI:1427339621
Name:ISHLEY, EVELYN LOURIDO (OT)
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:LOURIDO
Last Name:ISHLEY
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1463 REYNARD CRES
Mailing Address - Street 2:APT D
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-6025
Mailing Address - Country:US
Mailing Address - Phone:607-621-3645
Mailing Address - Fax:
Practice Address - Street 1:1400 FORDHAM DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-5368
Practice Address - Country:US
Practice Address - Phone:757-361-3954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-31
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010968-1225XP0200X
VA0119006676225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics