Provider Demographics
NPI:1609231596
Name:EVANS, TAMMIE
Entity Type:Individual
Prefix:
First Name:TAMMIE
Middle Name:
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 1:2841 REBEL DR
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-3120
Mailing Address - Country:US
Mailing Address - Phone:318-562-3707
Mailing Address - Fax:
Practice Address - Street 1:7505 PINES RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71129-3935
Practice Address - Country:US
Practice Address - Phone:318-562-3707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-21
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health