Healthcare Provider Details

I. General information

NPI: 1013762053
Provider Name (Legal Business Name): EMERALD SHOVAN EVANS CMTC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2024
Last Update Date: 04/23/2024
Certification Date: 04/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 EMBARCADERO
OAKLAND CA
94606-5119
US

IV. Provider business mailing address

1030 E 21ST ST
OAKLAND CA
94606-2628
US

V. Phone/Fax

Practice location:
  • Phone: 510-328-4098
  • Fax:
Mailing address:
  • Phone: 510-220-8530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number96289
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number96289
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: