Provider Demographics
NPI:1952673402
Name:EVOLA, DALE WILLIAM (LMFT)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:WILLIAM
Last Name:EVOLA
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:769 W BLAINE ST STE A
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-3970
Mailing Address - Country:US
Mailing Address - Phone:951-358-5186
Mailing Address - Fax:
Practice Address - Street 1:2045 SILVERTON RD NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-0100
Practice Address - Country:US
Practice Address - Phone:503-588-5351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-30
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT0799106H00000X
CALMFT48473106H00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist