Provider Demographics
NPI:1720489412
Name:EVANS, ALICEA
Entity Type:Individual
Prefix:
First Name:ALICEA
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 VILLAGE RD W
Mailing Address - Street 2:
Mailing Address - City:NORWOOD
Mailing Address - State:MA
Mailing Address - Zip Code:02062-2541
Mailing Address - Country:US
Mailing Address - Phone:617-970-2949
Mailing Address - Fax:
Practice Address - Street 1:3003 VILLAGE RD W
Practice Address - Street 2:
Practice Address - City:NORWOOD
Practice Address - State:MA
Practice Address - Zip Code:02062-2541
Practice Address - Country:US
Practice Address - Phone:617-970-2949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-12
Last Update Date:2017-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional