=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457606634
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN DAVID EVANS JR. LMHC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2012
-----------------------------------------------------
Last Update Date | 07/13/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 922 SW BAYA DR
-----------------------------------------------------
City | LAKE CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32025-4209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-754-9005
-----------------------------------------------------
Fax | 386-754-9017
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 922 SW BAYA DR
-----------------------------------------------------
City | LAKE CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32025-4209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-754-9005
-----------------------------------------------------
Fax | 386-754-9017
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | MH8268
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MH8268
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------