MEDICARE: STACI EVANS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	970127	OR

General Provider Information

NPI Number	:	1740674951
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACI EVANS

Provider Business Mailing Address
First Line	:	8015 SE COTTRELL RD
Second Line	:
City	:	BORING
State	:	OR
Zip	:	97009-6806
Country	:	US
Telephone Number	:	757-870-1171
Fax Number	:

Provider Business Practice Location Address
First Line	:	2927 SE VILLAGE LOOP
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98683-8119
Country	:	US
Telephone Number	:	360-253-3855
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/25/2015
Last Update Date	:	03/25/2015

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Directions to “ STACI EVANS ” Practice Location

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