Provider Demographics
NPI:1063555183
Name:KATZ, EVAN L (MC)
Entity type:Individual
Prefix:MR
First Name:EVAN
Middle Name:L
Last Name:KATZ
Suffix:
Gender:M
Credentials:MC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7450 HIGHWAY 92
Mailing Address - Street 2:SUITE 110
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-5235
Mailing Address - Country:US
Mailing Address - Phone:678-698-0311
Mailing Address - Fax:770-926-0762
Practice Address - Street 1:7450 HIGHWAY 92
Practice Address - Street 2:SUITE 110
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-5235
Practice Address - Country:US
Practice Address - Phone:678-698-0311
Practice Address - Fax:770-926-0762
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC001045101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional