Provider Demographics
NPI:1053655308
Name:EVANS, KATHERINE C
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:C
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 1:1908 FLINT RD SE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-6031
Mailing Address - Country:US
Mailing Address - Phone:256-340-9708
Mailing Address - Fax:256-340-9624
Practice Address - Street 1:210 PINE ST NW
Practice Address - Street 2:
Practice Address - City:HARTSELLE
Practice Address - State:AL
Practice Address - Zip Code:35640-2300
Practice Address - Country:US
Practice Address - Phone:256-773-0138
Practice Address - Fax:256-773-0140
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2614235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529917620Medicaid
AL1003819608OtherGROUP NPI
AL1003819608OtherGROUP NPI