Provider Demographics
NPI:1851028989
Name:EVANS, ELEXIS VICTORIA
Entity Type:Individual
Prefix:
First Name:ELEXIS
Middle Name:VICTORIA
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 1:123 MILESTONE DR
Mailing Address - Street 2:
Mailing Address - City:HAINES CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33844-9661
Mailing Address - Country:US
Mailing Address - Phone:863-280-5691
Mailing Address - Fax:
Practice Address - Street 1:8390 CHAMPIONS GATE BLVD STE 110
Practice Address - Street 2:
Practice Address - City:CHAMPIONS GATE
Practice Address - State:FL
Practice Address - Zip Code:33896-8311
Practice Address - Country:US
Practice Address - Phone:863-280-5691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-08
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician