Provider Demographics
NPI:1366756181
Name:EVANS, CODY RUDD (LCPC)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:RUDD
Last Name:EVANS
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1110 CALL CREEK DR.
Mailing Address - Street 2:SUITE 7
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3072
Mailing Address - Country:US
Mailing Address - Phone:208-233-2032
Mailing Address - Fax:208-233-2175
Practice Address - Street 1:475 YELLOWSTONE AVE
Practice Address - Street 2:STE E
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4528
Practice Address - Country:US
Practice Address - Phone:208-232-0021
Practice Address - Fax:208-232-0031
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-04
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDLCPC-4569101YM0800X
IDLPC4569101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health