Provider Demographics
NPI:1972510642
Name:EVANS, JOHN D
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:D
Last Name:EVANS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 113
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-0113
Mailing Address - Country:US
Mailing Address - Phone:803-931-0888
Mailing Address - Fax:803-252-7658
Practice Address - Street 1:1620 LADY ST
Practice Address - Street 2:SUITE A
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-3404
Practice Address - Country:US
Practice Address - Phone:803-931-0888
Practice Address - Fax:803-252-7658
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC37106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist