Provider Demographics
NPI:1376224923
Name:EVANS, TERA
Entity Type:Individual
Prefix:
First Name:TERA
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 1:6874 SUGAR PINE CT
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-7409
Mailing Address - Country:US
Mailing Address - Phone:909-610-5981
Mailing Address - Fax:
Practice Address - Street 1:5075 SHOREHAM PL STE 115
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-5927
Practice Address - Country:US
Practice Address - Phone:858-272-2662
Practice Address - Fax:858-272-2661
Is Sole Proprietor?:No
Enumeration Date:2023-07-27
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23-2777758106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician