Basic Information
| Provider Information | |||||||||
| NPI: | 1811131550 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | TAYLOR | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5579 | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977085579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417062768 | ||||||||
| FaxNumber: | 5417064760 | ||||||||
| Practice Location | |||||||||
| Address1: | 360 SW BOND ST STE 330 | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977023556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417062768 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2009 | ||||||||
| LastUpdateDate: | 06/16/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 1871 | OR | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 500609751 | 05 | OR | MEDICAID |