Provider Demographics
NPI:1518738269
Name:EVANS, THEO
Entity Type:Individual
Prefix:
First Name:THEO
Middle Name:
Last Name:EVANS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:THEO
Other - Middle Name:
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1321 CITIZENS BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-3946
Mailing Address - Country:US
Mailing Address - Phone:352-702-3727
Mailing Address - Fax:888-650-5089
Practice Address - Street 1:1321 CITIZENS BLVD STE C
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-3946
Practice Address - Country:US
Practice Address - Phone:352-702-3727
Practice Address - Fax:888-650-5089
Is Sole Proprietor?:No
Enumeration Date:2024-01-11
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator