Provider Demographics
NPI:1891413019
Name:EVANS, LAURIE ANN
Entity type:Individual
Prefix:MS
First Name:LAURIE
Middle Name:ANN
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 1:14706 AEGEAN WAY
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:TX
Mailing Address - Zip Code:78154-3400
Mailing Address - Country:US
Mailing Address - Phone:210-505-6484
Mailing Address - Fax:
Practice Address - Street 1:433 KITTY HAWK RD STE 211
Practice Address - Street 2:
Practice Address - City:UNIVERSAL CITY
Practice Address - State:TX
Practice Address - Zip Code:78148-3829
Practice Address - Country:US
Practice Address - Phone:210-763-8333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-15
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX667441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical