Healthcare Provider Details

I. General information

NPI: 1215438841
Provider Name (Legal Business Name): ANDREA DARLENE EVANCHO MPT, PCS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2018
Last Update Date: 02/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 E MICHIGAN AVE STE 145
LANSING MI
48912-1897
US

IV. Provider business mailing address

1200 E MICHIGAN AVE STE 145
LANSING MI
48912-1897
US

V. Phone/Fax

Practice location:
  • Phone: 517-364-5464
  • Fax:
Mailing address:
  • Phone: 517-364-5464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number5501011311
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: