Provider Demographics
NPI:1922429174
Name:EVANS, RODERICK (CRM)
Entity Type:Individual
Prefix:
First Name:RODERICK
Middle Name:
Last Name:EVANS
Suffix:
Gender:M
Credentials:CRM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 E MAIN ST STE 11
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-6022
Mailing Address - Country:US
Mailing Address - Phone:541-779-4658
Mailing Address - Fax:
Practice Address - Street 1:107 E MAIN ST STE 11
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-6022
Practice Address - Country:US
Practice Address - Phone:541-779-4658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-13
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12-CRM-013101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)