Provider Demographics
NPI:1275894693
Name:EVANS, RANDALL L (LCAC)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:L
Last Name:EVANS
Suffix:
Gender:M
Credentials:LCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 N ALABAMA ST
Mailing Address - Street 2:SUITE 320
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46204-1430
Mailing Address - Country:US
Mailing Address - Phone:317-634-6341
Mailing Address - Fax:317-464-9575
Practice Address - Street 1:615 N ALABAMA ST
Practice Address - Street 2:SUITE 320
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46204-1430
Practice Address - Country:US
Practice Address - Phone:317-634-6341
Practice Address - Fax:317-464-9575
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-01
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN86000158A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)