Provider Demographics
NPI:1114364502
Name:EVON, KATHIE RENEE
Entity Type:Individual
Prefix:MRS
First Name:KATHIE
Middle Name:RENEE
Last Name:EVON
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 1:757 GALT DR
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92019-3506
Mailing Address - Country:US
Mailing Address - Phone:619-672-2029
Mailing Address - Fax:
Practice Address - Street 1:6154 MISSION GORGE RD
Practice Address - Street 2:STE 120
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-3493
Practice Address - Country:US
Practice Address - Phone:619-285-1718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-27
Last Update Date:2013-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32728106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist