Provider Demographics
NPI:1275999062
Name:EVANS, EBONY
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:
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 1:405 GRETNA BLVD STE 205
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:LA
Mailing Address - Zip Code:70053-4971
Mailing Address - Country:US
Mailing Address - Phone:504-319-2885
Mailing Address - Fax:844-870-0727
Practice Address - Street 1:405 GRETNA BLVD STE 205
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70053-4971
Practice Address - Country:US
Practice Address - Phone:504-319-2885
Practice Address - Fax:844-870-0727
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-08
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6083101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA3228921Medicaid