Provider Demographics
NPI:1952635856
Name:EVANS LANE WELLNESS AND RECOVERY CENTER
Entity Type:Organization
Organization Name:EVANS LANE WELLNESS AND RECOVERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-793-2424
Mailing Address - Street 1:2090 EVANS LN
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95125-2072
Mailing Address - Country:US
Mailing Address - Phone:408-793-2406
Mailing Address - Fax:
Practice Address - Street 1:2090 EVANS LN
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95125-2072
Practice Address - Country:US
Practice Address - Phone:408-793-2406
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-24
Last Update Date:2009-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness