Healthcare Provider Details

I. General information

NPI: 1831489533
Provider Name (Legal Business Name): MICHELLE EVANS PSYD, BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2011
Last Update Date: 04/06/2024
Certification Date: 04/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5005 CANYON CREST DR
RIVERSIDE CA
92507-7721
US

IV. Provider business mailing address

377 BLUE DOLPHIN DR
PORT HUENEME CA
93041-3537
US

V. Phone/Fax

Practice location:
  • Phone: 747-208-5510
  • Fax:
Mailing address:
  • Phone: 805-341-9214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number0-09-3564
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY34964
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: