Healthcare Provider Details

I. General information

NPI: 1154908200
Provider Name (Legal Business Name): JOSEPH OTHELLO EVANS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2021
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

156 MADISON AVE NE
CONCORD NC
28025-3222
US

IV. Provider business mailing address

156 MADISON AVE NE
CONCORD NC
28025-3222
US

V. Phone/Fax

Practice location:
  • Phone: 336-858-6862
  • Fax:
Mailing address:
  • Phone: 336-858-6862
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA20180
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCAS-29928
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: