Provider Demographics
NPI:1417411927
Name:EVANS, TERRENCE
Entity type:Individual
Prefix:
First Name:TERRENCE
Middle Name:
Last Name:EVANS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12630 NW 38TH AVE
Mailing Address - Street 2:
Mailing Address - City:REDDICK
Mailing Address - State:FL
Mailing Address - Zip Code:32686-4067
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12630 NW 38TH AVE
Practice Address - Street 2:
Practice Address - City:REDDICK
Practice Address - State:FL
Practice Address - Zip Code:32686-4067
Practice Address - Country:US
Practice Address - Phone:352-361-2968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-29
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities