Provider Demographics
NPI:1164462636
Name:EVELY, CLYDE PRESTON JR (PHD)
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:PRESTON
Last Name:EVELY
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 PROVIDENCE RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27514-2206
Mailing Address - Country:US
Mailing Address - Phone:919-493-4400
Mailing Address - Fax:
Practice Address - Street 1:180 PROVIDENCE RD
Practice Address - Street 2:SUITE 4
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-2206
Practice Address - Country:US
Practice Address - Phone:919-493-4400
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1994103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2107748OtherCIGNA
NC046J1OtherBLUECROSS
NC6000610Medicaid