Provider Demographics
NPI:1578349775
Name:EVANS, CARMELLIA LATRAY (ALC)
Entity Type:Individual
Prefix:
First Name:CARMELLIA
Middle Name:LATRAY
Last Name:EVANS
Suffix:
Gender:F
Credentials:ALC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:237 STONECREST DR
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35242-6554
Mailing Address - Country:US
Mailing Address - Phone:205-522-6375
Mailing Address - Fax:
Practice Address - Street 1:237 STONECREST DR
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35242-6554
Practice Address - Country:US
Practice Address - Phone:205-522-6375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-04
Last Update Date:2023-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALALC04572101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health