Provider Demographics
NPI:1689031403
Name:EVANS, ROBERT
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:EVANS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 PUTNAM ST
Mailing Address - Street 2:
Mailing Address - City:WEST NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02465-2433
Mailing Address - Country:US
Mailing Address - Phone:617-964-5048
Mailing Address - Fax:
Practice Address - Street 1:44 PUTNAM ST
Practice Address - Street 2:
Practice Address - City:WEST NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02465-2433
Practice Address - Country:US
Practice Address - Phone:617-964-5048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-25
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1775103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist