Provider Demographics
NPI:1053988022
Name:EVANS, NICHOLAS J (AAC, SUDP)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:J
Last Name:EVANS
Suffix:
Gender:M
Credentials:AAC, SUDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1855 MAIN ST STE B206
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98248-9062
Mailing Address - Country:US
Mailing Address - Phone:360-230-8528
Mailing Address - Fax:
Practice Address - Street 1:1855 MAIN ST # B206
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:WA
Practice Address - Zip Code:98248-9062
Practice Address - Country:US
Practice Address - Phone:360-230-8528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-08
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP61269485101YA0400X
WACG61513376101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)