Provider Demographics
NPI:1497592281
Name:PEARSON, EVELINA (OT)
Entity type:Individual
Prefix:
First Name:EVELINA
Middle Name:
Last Name:PEARSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:EVELINA
Other - Middle Name:
Other - Last Name:WOZNIAK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1002 WISHARD BLVD STE 2021
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-4164
Practice Address - Country:US
Practice Address - Phone:317-944-8868
Practice Address - Fax:317-944-8860
Is Sole Proprietor?:No
Enumeration Date:2024-07-10
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
IN31008044A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300096735Medicaid
IN1104414805OtherANTHEM PTAN