Provider Demographics
NPI:1760999791
Name:EVANS, REBECCA LEE (MS, CGC)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:LEE
Last Name:EVANS
Suffix:
Gender:F
Credentials:MS, CGC
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:LEE
Other - Last Name:EELLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:1283 FIDDLEHEAD WAY
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-3821
Mailing Address - Country:US
Mailing Address - Phone:843-385-7322
Mailing Address - Fax:
Practice Address - Street 1:2 MEDICAL PARK RD STE 208
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6839
Practice Address - Country:US
Practice Address - Phone:843-385-7322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-29
Last Update Date:2017-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN74000042A170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN74000042AOtherINDIANA MEDICAL LICENSING BOARD