Provider Demographics
NPI:1962860452
Name:EVANS, MARY ALISA (LPCA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ALISA
Last Name:EVANS
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 HIGHWOODS BLVD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-1027
Mailing Address - Country:US
Mailing Address - Phone:919-714-7500
Mailing Address - Fax:919-714-7367
Practice Address - Street 1:3000 HIGHWOODS BLVD
Practice Address - Street 2:SUITE 310
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27604-1027
Practice Address - Country:US
Practice Address - Phone:919-714-7500
Practice Address - Fax:919-714-7367
Is Sole Proprietor?:No
Enumeration Date:2016-01-29
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA11967101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC13674534OtherCAQHID