MEDICARE: MS. MINIKA NICOLE EVANS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1588912786
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MINIKA NICOLE EVANS

Provider Business Mailing Address
First Line	:	1500 S HAVEN AVE STE 250
Second Line	:
City	:	ONTARIO
State	:	CA
Zip	:	91761-2973
Country	:	US
Telephone Number	:	909-749-5204
Fax Number	:

Provider Business Practice Location Address
First Line	:	1500 S HAVEN AVE STE 250
Second Line	:
City	:	ONTARIO
State	:	CA
Zip	:	91761-2973
Country	:	US
Telephone Number	:	909-749-5204
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/17/2012
Last Update Date	:	06/12/2020

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