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General NPI Number Information
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NPI Number | 1649461500
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Entity Type | Individual
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Provider Name | ISSAC CORRETTE EVANS JR.
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Gender | Male
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Dates
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Enumeration Date | 08/06/2007
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Last Update Date | 01/10/2023
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Provider Practice Location Address
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Address Line | 2810 HARLEM AVE
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City | BALTIMORE
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State | MD
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Zip | 21216
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Country | US
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Telephone | 410-814-2179
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Fax |
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Provider Business Mailing Address
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Address Line | 5404 CATALPHA RD
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City | BALTIMORE
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State | MD
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Zip | 21214-1925
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Country | US
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Telephone | 443-453-7746
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Fax |
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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 | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number |
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License Number State |
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