Provider Demographics
NPI:1902131329
Name:STUART, EVAN MICHAEL (OTR/L)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:MICHAEL
Last Name:STUART
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6401 SANTA MONICA AVE NE APT 1101
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4162
Mailing Address - Country:US
Mailing Address - Phone:978-618-7500
Mailing Address - Fax:
Practice Address - Street 1:2301 GOLF COURSE RD SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-4971
Practice Address - Country:US
Practice Address - Phone:978-618-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-03
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4440225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist