Provider Demographics
NPI:1295986602
Name:SMITH, EVANGELINE WASHINGTON
Entity type:Individual
Prefix:MRS
First Name:EVANGELINE
Middle Name:WASHINGTON
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 MALLARD CIR
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35405-6772
Mailing Address - Country:US
Mailing Address - Phone:205-391-4737
Mailing Address - Fax:
Practice Address - Street 1:421 23RD AVE E
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35404-3039
Practice Address - Country:US
Practice Address - Phone:205-553-5801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-03
Last Update Date:2008-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL251S00000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health