Individual
KELLY JEAN EVENSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
1291 CRAIG AVE, LAKEPORT, CA 95453-5704
(707) 263-6382
Mailing address
10641 SUNSET RIDGE DR, KELSEYVILLE, CA 95451-9505
(920) 636-3399
Taxonomy
Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
Primary
4499
CA
Other
Enumeration date
08/03/2020
Last updated
08/03/2020
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