Provider Demographics
NPI:1760666275
Name:EVANS, MIA
Entity Type:Individual
Prefix:MISS
First Name:MIA
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 1:320 W TEMPLE ST
Mailing Address - Street 2:9TH, FL
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90012-3208
Mailing Address - Country:US
Mailing Address - Phone:213-974-4704
Mailing Address - Fax:
Practice Address - Street 1:320 W TEMPLE ST
Practice Address - Street 2:9TH, FL
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012-3208
Practice Address - Country:US
Practice Address - Phone:213-974-4704
Practice Address - Fax:213-620-1405
Is Sole Proprietor?:No
Enumeration Date:2007-12-19
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator