Healthcare Provider Details

I. General information

NPI: 1326633827
Provider Name (Legal Business Name): LORI MARTIN-EVANS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2021
Last Update Date: 03/05/2021
Certification Date: 02/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36161 N CENTER ST
CLARKSBURG CA
95612
US

IV. Provider business mailing address

PO BOX 106
CLARKSBURG CA
95612-0106
US

V. Phone/Fax

Practice location:
  • Phone: 916-744-1966
  • Fax:
Mailing address:
  • Phone: 903-390-0288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2290
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: