Provider Demographics
NPI:1780716407
Name:EVANS, JAMES H (PHD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:H
Last Name:EVANS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:402 W BIJOU ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80905-1309
Mailing Address - Country:US
Mailing Address - Phone:719-520-1102
Mailing Address - Fax:719-302-6686
Practice Address - Street 1:402 W BIJOU ST
Practice Address - Street 2:SUITE C
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80905-1309
Practice Address - Country:US
Practice Address - Phone:719-520-1102
Practice Address - Fax:719-302-6686
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO568103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07104672Medicaid
COR21087Medicare UPIN
CO92956Medicare PIN