Provider Demographics
NPI:1649461500
Name:EVANS, ISSAC CORRETTE JR
Entity type:Individual
Prefix:
First Name:ISSAC
Middle Name:CORRETTE
Last Name:EVANS
Suffix:JR
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 1:5404 CATALPHA RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21214-1925
Mailing Address - Country:US
Mailing Address - Phone:443-453-7746
Mailing Address - Fax:
Practice Address - Street 1:2810 HARLEM AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21216
Practice Address - Country:US
Practice Address - Phone:410-814-2179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician