Provider Demographics
NPI:1578386942
Name:EVANS, DOMONIQUE (MS, LPC)
Entity type:Individual
Prefix:
First Name:DOMONIQUE
Middle Name:
Last Name:EVANS
Suffix:
Gender:M
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:365 E MEEHAN AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19119-1935
Mailing Address - Country:US
Mailing Address - Phone:267-254-8264
Mailing Address - Fax:
Practice Address - Street 1:1300 VIRGINIA DR
Practice Address - Street 2:
Practice Address - City:FORT WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:19034-3221
Practice Address - Country:US
Practice Address - Phone:484-202-0751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-05
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC17769101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional