Provider Demographics
NPI:1386216802
Name:EVANS, ISAAC DANIEL
Entity Type:Individual
Prefix:
First Name:ISAAC
Middle Name:DANIEL
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 1:1306 BYRNE AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-5123
Mailing Address - Country:US
Mailing Address - Phone:615-498-8018
Mailing Address - Fax:
Practice Address - Street 1:570 E 10TH ST
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-1876
Practice Address - Country:US
Practice Address - Phone:931-372-7117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5107101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional