Provider Demographics
NPI:1720753601
Name:EVANS, BRANDON ANTONIO (BEHAVIOR TECHNICIAN)
Entity type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:ANTONIO
Last Name:EVANS
Suffix:
Gender:M
Credentials:BEHAVIOR TECHNICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30205 TAVARES RIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-4465
Mailing Address - Country:US
Mailing Address - Phone:352-874-9802
Mailing Address - Fax:
Practice Address - Street 1:30205 TAVARES RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-4465
Practice Address - Country:US
Practice Address - Phone:352-874-9802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-12
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician