{
"Npi": {
"NPI": "1790331858",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "Y",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "EVANS",
"FirstName": "ELISSA",
"MiddleName": "CAE",
"NamePrefix": null,
"NameSuffix": null,
"Credential": "LCSW",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "PO BOX 784",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "PANACA",
"MailingAddressStateName": "NV",
"MailingAddressPostalCode": "89042-0784",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "702-461-6484",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "88 E FIDDLERS CANYON RD STE 122",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "CEDAR CITY",
"PracticeLocationAddressStateName": "UT",
"PracticeLocationAddressPostalCode": "84721-9787",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "702-775-2738",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "08/14/2019",
"LastUpdateDate": "02/18/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "F",
"Gender": "Female",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "101YA0400X",
"TaxonomyName": "Addiction (Substance Use Disorder) Counselor",
"LicenseNumber": "00833-C",
"LicenseNumberStateCode": "NV",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "101YM0800X",
"TaxonomyName": "Mental Health Counselor",
"LicenseNumber": "13063034-3501",
"LicenseNumberStateCode": "UT",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "101YM0800X",
"TaxonomyName": "Mental Health Counselor",
"LicenseNumber": "11968-C",
"LicenseNumberStateCode": "NV",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": null
}
}