Provider Demographics
NPI:1881224525
Name:EVANS, KRISTY
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:
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 1:7705 SLEEPY LAGOON WAY
Mailing Address - Street 2:
Mailing Address - City:FLOWERY BRANCH
Mailing Address - State:GA
Mailing Address - Zip Code:30542-7559
Mailing Address - Country:US
Mailing Address - Phone:951-893-0014
Mailing Address - Fax:
Practice Address - Street 1:7705 SLEEPY LAGOON WAY
Practice Address - Street 2:
Practice Address - City:FLOWERY BRANCH
Practice Address - State:GA
Practice Address - Zip Code:30542-7559
Practice Address - Country:US
Practice Address - Phone:951-893-0014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-22
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA150110193103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool