Provider Demographics
NPI:1578215828
Name:EVANS, ALIYAH DENALI
Entity Type:Individual
Prefix:
First Name:ALIYAH
Middle Name:DENALI
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 1:150 GLEN COVE MARINA RD E STE 102
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94591-7237
Mailing Address - Country:US
Mailing Address - Phone:707-553-1784
Mailing Address - Fax:
Practice Address - Street 1:150 GLEN COVE MARINA RD E STE 102
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94591-7237
Practice Address - Country:US
Practice Address - Phone:707-553-1784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-18
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA10981963Medicaid
CA10918963Medicaid