Healthcare Provider Details

I. General information

NPI: 1578697405
Provider Name (Legal Business Name): TERRESSA YAVONNE EVANS LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 04/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 VICTORIA STREET
WILLIAMSON WV
25661
US

IV. Provider business mailing address

P.O. BOX 405
WILLIAMSON WV
25661
US

V. Phone/Fax

Practice location:
  • Phone: 304-235-1444
  • Fax: 304-235-1444
Mailing address:
  • Phone: 304-235-1444
  • Fax: 304-235-1444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number2006-
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: