Provider Demographics
NPI:1861560963
Name:EVANS, BRUCE SANFORD (LMFT, LPC, CSAC)
Entity type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:SANFORD
Last Name:EVANS
Suffix:
Gender:M
Credentials:LMFT, LPC, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11606 GORDON SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23236-2513
Mailing Address - Country:US
Mailing Address - Phone:804-378-6733
Mailing Address - Fax:804-365-8575
Practice Address - Street 1:11606 GORDON SCHOOL RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23236-2513
Practice Address - Country:US
Practice Address - Phone:804-378-6733
Practice Address - Fax:804-365-8575
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701002999101YP2500X
VA0717000980106H00000X
LA770106H00000X
VA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA54-12145Medicaid