Provider Demographics
NPI:1104127133
Name:EVANS, CORLEY (BS, MHPP)
Entity type:Individual
Prefix:
First Name:CORLEY
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:BS, MHPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5537 BLEAUX AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-0737
Mailing Address - Country:US
Mailing Address - Phone:479-872-5580
Mailing Address - Fax:479-872-5581
Practice Address - Street 1:9914 I-30
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72209-4201
Practice Address - Country:US
Practice Address - Phone:501-565-8501
Practice Address - Fax:501-565-1219
Is Sole Proprietor?:No
Enumeration Date:2010-11-08
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR116378726Medicaid