Provider Demographics
NPI:1821815630
Name:EVANS, MYA (RBT)
Entity type:Individual
Prefix:
First Name:MYA
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 N 44TH ST UNIT 1012
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-5758
Mailing Address - Country:US
Mailing Address - Phone:651-239-9829
Mailing Address - Fax:
Practice Address - Street 1:4616 N 51ST AVE STE 216
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85031-1716
Practice Address - Country:US
Practice Address - Phone:602-612-8776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1177338106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician