Basic Information
| Provider Information | |||||||||
| NPI: | 1346371077 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | |||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4450 W EAU GALLIE BLVD | ||||||||
| Address2: | 200 | ||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329347213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217523100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4450 W EAU GALLIE BLVD | ||||||||
| Address2: | 200 | ||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329347213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217523100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2007 | ||||||||
| LastUpdateDate: | 01/15/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | LCMFT0241021200 | FL | Y | Other Service Providers | Case Manager/Care Coordinator | 101YP1600X | LCMFT0241021200 | FL | N | Behavioral Health & Social Service Providers | Counselor | Pastoral |
ID Information
| ID | Type | State | Issuer | Description | 768243300 | 05 | FL | MEDICAID | 076542200 | 05 | FL | MEDICAID |