Provider Demographics
NPI:1649349655
Name:EVANS, COREY EVONT (MA CCC-SLP)
Entity type:Individual
Prefix:MR
First Name:COREY
Middle Name:EVONT
Last Name:EVANS
Suffix:
Gender:M
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 390335
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30039
Mailing Address - Country:US
Mailing Address - Phone:404-449-7902
Mailing Address - Fax:770-979-7561
Practice Address - Street 1:4097 TROTTERS WAY DRIVE
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30039
Practice Address - Country:US
Practice Address - Phone:404-449-7902
Practice Address - Fax:770-979-7561
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP005335235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00955028DMedicaid