Provider Demographics
NPI:1770035529
Name:EVANS, BRYCE (BS)
Entity Type:Individual
Prefix:
First Name:BRYCE
Middle Name:
Last Name:EVANS
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2612 RAYMA CT
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89503-5707
Mailing Address - Country:US
Mailing Address - Phone:775-220-5499
Mailing Address - Fax:
Practice Address - Street 1:2612 RAYMA CT
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89503-5707
Practice Address - Country:US
Practice Address - Phone:775-220-5499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-27
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1245781160Medicaid