Provider Demographics
NPI:1679931695
Name:HARISON, EVELYN CUBBERLY (LGPC)
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:CUBBERLY
Last Name:HARISON
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:EVELYN
Other - Middle Name:
Other - Last Name:CUBBERLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4201 CONNECTICUT AVE NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20008-1158
Mailing Address - Country:US
Mailing Address - Phone:210-213-6284
Mailing Address - Fax:
Practice Address - Street 1:4201 CONNECTICUT AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20008-1158
Practice Address - Country:US
Practice Address - Phone:210-213-6284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-04
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC00018101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional