Provider Demographics
NPI:1083129365
Name:EVANS, DESRA
Entity Type:Individual
Prefix:
First Name:DESRA
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 1:152 N 400 W
Mailing Address - Street 2:
Mailing Address - City:EPHRAIM
Mailing Address - State:UT
Mailing Address - Zip Code:84627-5549
Mailing Address - Country:US
Mailing Address - Phone:435-283-8400
Mailing Address - Fax:435-283-8401
Practice Address - Street 1:255 S MAIN ST
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:UT
Practice Address - Zip Code:84701-2699
Practice Address - Country:US
Practice Address - Phone:435-896-8236
Practice Address - Fax:435-896-9584
Is Sole Proprietor?:No
Enumeration Date:2017-12-07
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health