Provider Demographics
NPI:1679567499
Name:KELLEY, EVAN EARLE (MSPT, OCS)
Entity type:Individual
Prefix:MR
First Name:EVAN
Middle Name:EARLE
Last Name:KELLEY
Suffix:
Gender:M
Credentials:MSPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6900 ALDEN DR
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82005-3906
Mailing Address - Country:US
Mailing Address - Phone:307-773-3406
Mailing Address - Fax:
Practice Address - Street 1:6900 ALDEN DR
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82005-3906
Practice Address - Country:US
Practice Address - Phone:307-773-3406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11277174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist