Provider Demographics
NPI:1518166750
Name:EVANS, DIANE C (LCSW)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:C
Last Name:EVANS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 CANTRILL DR
Mailing Address - Street 2:118
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95618-7757
Mailing Address - Country:US
Mailing Address - Phone:530-750-2020
Mailing Address - Fax:
Practice Address - Street 1:715 6TH ST
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-3809
Practice Address - Country:US
Practice Address - Phone:530-750-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-17
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW86441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ06185ZOtherMEDICARE PTAN