Provider Demographics
NPI:1790026847
Name:EVANS, KAITLIN GAGE
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:GAGE
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 1:3636 W IMPERIAL HWY
Mailing Address - Street 2:#112
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90303-2751
Mailing Address - Country:US
Mailing Address - Phone:910-273-2018
Mailing Address - Fax:
Practice Address - Street 1:18646 OXNARD ST
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-1411
Practice Address - Country:US
Practice Address - Phone:818-996-1051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-13
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor