Provider Demographics
NPI:1649889536
Name:EVANS, ELIJAH B (PEER SUPPORT CERT)
Entity type:Individual
Prefix:
First Name:ELIJAH
Middle Name:B
Last Name:EVANS
Suffix:
Gender:M
Credentials:PEER SUPPORT CERT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122A OLIVE BRANCH DR
Mailing Address - Street 2:
Mailing Address - City:YOUNGSVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70592-5121
Mailing Address - Country:US
Mailing Address - Phone:337-376-3523
Mailing Address - Fax:
Practice Address - Street 1:1120 W HUTCHINSON AVE
Practice Address - Street 2:
Practice Address - City:CROWLEY
Practice Address - State:LA
Practice Address - Zip Code:70526-4124
Practice Address - Country:US
Practice Address - Phone:337-250-4263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA011576884171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator