Healthcare Provider Details

I. General information

NPI: 1003797986
Provider Name (Legal Business Name): MARK CONSTANTINE EVANOFF PPS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2025
Last Update Date: 09/09/2025
Certification Date: 09/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

441 W LINWOOD AVE
TURLOCK CA
95380-6221
US

IV. Provider business mailing address

441 W LINWOOD AVE
TURLOCK CA
95380-6221
US

V. Phone/Fax

Practice location:
  • Phone: 209-667-9047
  • Fax:
Mailing address:
  • Phone: 209-667-9047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number140161190
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: