Provider Demographics
NPI:1770128332
Name:EVANS, DEBBRENA
Entity type:Individual
Prefix:
First Name:DEBBRENA
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12575 MAJESTIC WAY
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-5976
Mailing Address - Country:US
Mailing Address - Phone:269-228-6052
Mailing Address - Fax:
Practice Address - Street 1:12575 MAJESTIC WAY
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-5976
Practice Address - Country:US
Practice Address - Phone:269-228-6052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-07
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty