Provider Demographics
NPI:1861508921
Name:EVANS, JOHN LEE (PHD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:LEE
Last Name:EVANS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15525 POMERADO RD
Mailing Address - Street 2:SUITE E-4
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-2435
Mailing Address - Country:US
Mailing Address - Phone:858-673-9600
Mailing Address - Fax:858-451-1104
Practice Address - Street 1:15525 POMERADO RD
Practice Address - Street 2:SUITE E-4
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-2435
Practice Address - Country:US
Practice Address - Phone:858-673-9600
Practice Address - Fax:858-451-1104
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12242103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CP12242Medicare ID - Type Unspecified