Provider Demographics
NPI:1851586820
Name:EVANS, SALLY (MFT)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3736 MT DIABLO BLVD
Mailing Address - Street 2:#100
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-3679
Mailing Address - Country:US
Mailing Address - Phone:925-962-1188
Mailing Address - Fax:925-888-8526
Practice Address - Street 1:3736 MT DIABLO BLVD
Practice Address - Street 2:#100
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-3679
Practice Address - Country:US
Practice Address - Phone:925-962-1188
Practice Address - Fax:925-888-8526
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-12
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC27147106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist