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General NPI Number Information
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NPI Number | 1366756181
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Entity Type | Individual
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Provider Name | CODY RUDD EVANS LCPC
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Gender | Male
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Dates
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Enumeration Date | 08/04/2010
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Last Update Date | 06/15/2016
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Provider Practice Location Address
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Address Line | 475 YELLOWSTONE AVE STE E
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City | POCATELLO
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State | ID
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Zip | 83201-4528
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Country | US
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Telephone | 208-232-0021
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Fax | 208-232-0031
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Provider Business Mailing Address
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Address Line | 1110 CALL CREEK DR. SUITE 7
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City | POCATELLO
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State | ID
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Zip | 83201-3072
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Country | US
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Telephone | 208-233-2032
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Fax | 208-233-2175
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | LCPC-4569
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | LPC4569
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License Number State | ID
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