Provider Demographics
NPI:1457689887
Name:EVANS, LISA CAROL (MA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:CAROL
Last Name:EVANS
Suffix:
Gender:F
Credentials:MA
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 2214
Mailing Address - Street 2:
Mailing Address - City:WYLIE
Mailing Address - State:TX
Mailing Address - Zip Code:75098-2214
Mailing Address - Country:US
Mailing Address - Phone:972-522-8448
Mailing Address - Fax:
Practice Address - Street 1:808 S BALLARD AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:WYLIE
Practice Address - State:TX
Practice Address - Zip Code:75098-4224
Practice Address - Country:US
Practice Address - Phone:972-522-8448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-23
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX65594101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional