Provider Demographics
NPI:1205359601
Name:EVANS, RUBY NOLA
Entity Type:Individual
Prefix:
First Name:RUBY
Middle Name:NOLA
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 1:204 N PIERCE ST
Mailing Address - Street 2:
Mailing Address - City:BURNET
Mailing Address - State:TX
Mailing Address - Zip Code:78611-2530
Mailing Address - Country:US
Mailing Address - Phone:512-468-4098
Mailing Address - Fax:
Practice Address - Street 1:6448 E HWY 290 STE E114
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78723-1076
Practice Address - Country:US
Practice Address - Phone:512-468-4098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-18
Last Update Date:2017-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX69175101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty