Provider Demographics
NPI:1083412456
Name:EVANS, ANDRE (AMFT-122136)
Entity type:Individual
Prefix:
First Name:ANDRE
Middle Name:
Last Name:EVANS
Suffix:
Gender:
Credentials:AMFT-122136
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:456 OLD NEWPORT BLVD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-4211
Mailing Address - Country:US
Mailing Address - Phone:949-781-9025
Mailing Address - Fax:
Practice Address - Street 1:456 OLD NEWPORT BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-4211
Practice Address - Country:US
Practice Address - Phone:949-781-9025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-03
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA122136106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist