Provider Demographics
NPI:1013410265
Name:EVANGELISTA, JAMES A
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:A
Last Name:EVANGELISTA
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 1:20 ANTELOPE BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:RED BLUFF
Mailing Address - State:CA
Mailing Address - Zip Code:96080
Mailing Address - Country:US
Mailing Address - Phone:530-567-7600
Mailing Address - Fax:530-727-9094
Practice Address - Street 1:20 ANTELOPE BOULEVARD
Practice Address - Street 2:
Practice Address - City:RED BLUFF
Practice Address - State:CA
Practice Address - Zip Code:96080
Practice Address - Country:US
Practice Address - Phone:530-567-7600
Practice Address - Fax:530-727-9094
Is Sole Proprietor?:No
Enumeration Date:2018-03-14
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA139378106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist