Provider Demographics
NPI:1336787589
Name:EVANS, TINA C
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:C
Last Name:EVANS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3341 YOUREE DR STE 205
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-2149
Mailing Address - Country:US
Mailing Address - Phone:318-219-4167
Mailing Address - Fax:
Practice Address - Street 1:3341 YOUREE DR STE 205
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-2149
Practice Address - Country:US
Practice Address - Phone:318-219-4167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-18
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician