Provider Demographics
NPI:1386790442
Name:EVANS, ROBERT S (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:S
Last Name:EVANS
Suffix:
Gender:M
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 WILLOW TRACE CIR APT 5
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-8814
Mailing Address - Country:US
Mailing Address - Phone:336-682-2730
Mailing Address - Fax:336-682-2730
Practice Address - Street 1:114 WILLOW TRACE CIR APT 5
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-8814
Practice Address - Country:US
Practice Address - Phone:336-682-2730
Practice Address - Fax:336-682-2730
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4302235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC133T3OtherBCBS
NC7411906Medicaid