Provider Demographics
NPI:1053867408
Name:AMEZCUA, EVELYN
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:
Last Name:AMEZCUA
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 1:1237 GREEN OAK RD
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92081-7821
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1237 GREEN OAK RD
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92081-7821
Practice Address - Country:US
Practice Address - Phone:760-598-2803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-26
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor