Provider Demographics
NPI:1114112455
Name:EVENHUIS, ERIC FRANZ (MFT)
Entity Type:Individual
Prefix:PROF
First Name:ERIC
Middle Name:FRANZ
Last Name:EVENHUIS
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10808 FOOTHILL BLVD
Mailing Address - Street 2:160-427
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-3889
Mailing Address - Country:US
Mailing Address - Phone:909-481-5800
Mailing Address - Fax:909-481-5872
Practice Address - Street 1:6113 KIRKWOOD AVE
Practice Address - Street 2:
Practice Address - City:ALTA LOMA
Practice Address - State:CA
Practice Address - Zip Code:91701-3417
Practice Address - Country:US
Practice Address - Phone:909-980-5900
Practice Address - Fax:909-466-4203
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC-13882174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFC13882061907OtherSERVICE LOCATION