Provider Demographics
NPI:1326417643
Name:EVANS, WILLIAM TODD
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:TODD
Last Name:EVANS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1918 BONITA AVENUE
Mailing Address - Street 2:SUITE 200, BOX #41029
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94704
Mailing Address - Country:US
Mailing Address - Phone:510-334-1124
Mailing Address - Fax:
Practice Address - Street 1:12555 W JEFFERSON BLVD STE 301
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-7032
Practice Address - Country:US
Practice Address - Phone:424-443-5555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-16
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA924861041C0700X
CA72263104100000X, 101YM0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program