Healthcare Provider Details

I. General information

NPI: 1033628995
Provider Name (Legal Business Name): STACIA LATORRIA EVANS BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2017
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 W BOND AVE
WEST MEMPHIS AR
72301-3907
US

IV. Provider business mailing address

233 W BOND AVE
WEST MEMPHIS AR
72301-3907
US

V. Phone/Fax

Practice location:
  • Phone: 731-269-8694
  • Fax:
Mailing address:
  • Phone: 901-275-9491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-17-27070
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: