Basic Information
| Provider Information | |||||||||
| NPI: | 1184775850 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVANKO | ||||||||
| FirstName: | ROBERT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8132 KING HELIE BLVD | ||||||||
| Address2: | |||||||||
| City: | NEW PORT RICHEY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346531435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278414207 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8132 KING HELIE BLVD | ||||||||
| Address2: | |||||||||
| City: | NEW PORT RICHEY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346531435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278343959 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2007 | ||||||||
| LastUpdateDate: | 09/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | MH4474 | FL | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 762377100 | 05 | FL | MEDICAID |