Provider Demographics
NPI:1477856524
Name:EVANS, JOHN S JR (LCSW, LMFT)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:S
Last Name:EVANS
Suffix:JR
Gender:M
Credentials:LCSW, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3515 WHITE OAK DR
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76502-3605
Mailing Address - Country:US
Mailing Address - Phone:254-778-1599
Mailing Address - Fax:254-778-1599
Practice Address - Street 1:2201 S CLEAR CREEK RD
Practice Address - Street 2:METROPLEX PAVILION SUITE A-18
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-4110
Practice Address - Country:US
Practice Address - Phone:254-563-5572
Practice Address - Fax:254-778-1599
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-13
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX136061041C0700X
TX460106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0257750Medicaid