Provider Demographics
NPI:1043795875
Name:EVANS, MARSHA
Entity Type:Individual
Prefix:
First Name:MARSHA
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2520 CARMICHAEL WAY APT 36
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-5371
Mailing Address - Country:US
Mailing Address - Phone:860-655-3753
Mailing Address - Fax:
Practice Address - Street 1:100 PRISON RD
Practice Address - Street 2:
Practice Address - City:REPRESA
Practice Address - State:CA
Practice Address - Zip Code:95671-3000
Practice Address - Country:US
Practice Address - Phone:860-655-3753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-27
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103T00000XBehavioral Health & Social Service ProvidersPsychologist