Provider Demographics
NPI:1477792679
Name:EVANS, RONALD HOWARD (EDD)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:HOWARD
Last Name:EVANS
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 54911
Mailing Address - Street 2:415 SOUTH ST. MS061, BRANDEIS UNIVERSITY
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02454-9110
Mailing Address - Country:US
Mailing Address - Phone:781-736-3730
Mailing Address - Fax:781-736-3731
Practice Address - Street 1:415 SOUTH ST.
Practice Address - Street 2:BRANDEIS UNIVERSITY, PSYCHOLOGICAL COUNSELING, MAILMAN
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02454-9110
Practice Address - Country:US
Practice Address - Phone:781-736-3730
Practice Address - Fax:781-736-3731
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-11
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA4613103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
W04449OtherBLUE CROSS/BLUE SH..