Provider Demographics
NPI:1255500203
Name:DR KATIE EVANS INC
Entity Type:Organization
Organization Name:DR KATIE EVANS INC
Other - Org Name:EVANS & SULLIVAN
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:TREATMENT DIRECTOR CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:EVANS
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, CDP, RC, NCACII
Authorized Official - Phone:503-756-6117
Mailing Address - Street 1:19943 SW JETTE LN
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-2789
Mailing Address - Country:US
Mailing Address - Phone:503-756-6117
Mailing Address - Fax:503-524-3778
Practice Address - Street 1:19943 SW JETTE LN
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-2789
Practice Address - Country:US
Practice Address - Phone:503-756-6117
Practice Address - Fax:503-524-3778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-25
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR860106101YA0400X
WACP00004591101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1615-01OtherPBH
OR100000012349OtherREGENCE
0001152747OtherMHN SERVICES
OR283365OtherMULTIPLAN
OR669401100000OtherLIFEWISE
OR3006890OtherREGENCE BLUECROSS BLUESHIELD OF OREGON