Provider Demographics
NPI:1790023380
Name:EVANS, KIMBERLY SUE
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SUE
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 1:14413 S 26TH WEST AVE
Mailing Address - Street 2:
Mailing Address - City:GLENPOOL
Mailing Address - State:OK
Mailing Address - Zip Code:74033-3306
Mailing Address - Country:US
Mailing Address - Phone:918-381-3226
Mailing Address - Fax:
Practice Address - Street 1:6202 S LEWIS AVE
Practice Address - Street 2:SUITE H
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1099
Practice Address - Country:US
Practice Address - Phone:918-949-4086
Practice Address - Fax:918-949-3638
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-16
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200287120AMedicaid