Provider Demographics
NPI:1639612039
Name:EVANS, DELORA
Entity Type:Individual
Prefix:
First Name:DELORA
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DELORA
Other - Middle Name:
Other - Last Name:EVANS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:7272 MARVIN D LOVE FWY
Mailing Address - Street 2:#722
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75237-3173
Mailing Address - Country:US
Mailing Address - Phone:469-766-1251
Mailing Address - Fax:
Practice Address - Street 1:7272 MARVIN D LOVE FWY
Practice Address - Street 2:#722
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237-3173
Practice Address - Country:US
Practice Address - Phone:469-766-1251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-02
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX69477101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional