Provider Demographics
NPI:1669806949
Name:EVANS, ROGER (CADC II, ICADC)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:EVANS
Suffix:
Gender:M
Credentials:CADC II, ICADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:771 W BLAINE ST STE D
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-3940
Mailing Address - Country:US
Mailing Address - Phone:951-722-7260
Mailing Address - Fax:
Practice Address - Street 1:771 W BLAINE ST STE D
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-3940
Practice Address - Country:US
Practice Address - Phone:951-955-8572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-22
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13377101YA0400X
CAA035000816171M00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator