Provider Demographics
NPI:1588912786
Name:EVANS, MINIKA NICOLE
Entity type:Individual
Prefix:MS
First Name:MINIKA
Middle Name:NICOLE
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 1:1500 S HAVEN AVE STE 250
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-2973
Mailing Address - Country:US
Mailing Address - Phone:909-749-5204
Mailing Address - Fax:
Practice Address - Street 1:1500 S HAVEN AVE STE 250
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-2973
Practice Address - Country:US
Practice Address - Phone:909-749-5204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-17
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician