Provider Demographics
NPI:1982885968
Name:EVANS PSYCHOLOGICAL
Entity Type:Organization
Organization Name:EVANS PSYCHOLOGICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:C
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:402-330-1537
Mailing Address - Street 1:12728 AUGUSTA AVE
Mailing Address - Street 2:STE 150
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-3754
Mailing Address - Country:US
Mailing Address - Phone:402-330-1537
Mailing Address - Fax:402-330-9331
Practice Address - Street 1:12728 AUGUSTA AVE
Practice Address - Street 2:STE 150
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-3754
Practice Address - Country:US
Practice Address - Phone:402-330-1537
Practice Address - Fax:402-330-9331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-19
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE77103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47078906000Medicaid
NE089714Medicare PIN
NE092617Medicare PIN