Provider Demographics
NPI:1003210873
Name:EVA LIFE GIVER INC.
Entity Type:Organization
Organization Name:EVA LIFE GIVER INC.
Other - Org Name:DEVAUGHN INTERVENTION TEACH AND TREAT OPTIONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:EVA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEVAUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CAC-AD
Authorized Official - Phone:443-271-8046
Mailing Address - Street 1:5003 ARDMORE WAY
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21206-5004
Mailing Address - Country:US
Mailing Address - Phone:443-271-8046
Mailing Address - Fax:443-873-8959
Practice Address - Street 1:4804 YORK RD STE 2
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21212-4401
Practice Address - Country:US
Practice Address - Phone:443-873-8958
Practice Address - Fax:443-873-8959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-22
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1699076562Medicaid