Provider Demographics
NPI:1982615936
Name:EVANS, JUDITH KATHLEEN (LPC)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:KATHLEEN
Last Name:EVANS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 VALLEY VIEW DR N
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-3209
Mailing Address - Country:US
Mailing Address - Phone:817-480-8703
Mailing Address - Fax:
Practice Address - Street 1:2707 AIRPORT FWY
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76111-2370
Practice Address - Country:US
Practice Address - Phone:817-480-8703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16944101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1671521Medicaid