Provider Demographics
NPI:1851251961
Name:WALTERS, EVAN
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:WALTERS
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14914 N 600 E
Mailing Address - Street 2:
Mailing Address - City:ROANN
Mailing Address - State:IN
Mailing Address - Zip Code:46974-9268
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 BROADWAY PLZ
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-1052
Practice Address - Country:US
Practice Address - Phone:765-753-8829
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-11-12
Last Update Date:2025-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant