Basic Information
| Provider Information | |||||||||
| NPI: | 1609803501 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | HARRY | ||||||||
| MiddleName: | MONROE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 845347 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752845347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146455555 | ||||||||
| FaxNumber: | 2146485627 | ||||||||
| Practice Location | |||||||||
| Address1: | 6201 HARRY HINES BLVD. | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752357709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146455555 | ||||||||
| FaxNumber: | 2146489627 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2006 | ||||||||
| LastUpdateDate: | 08/07/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | 23061 | TX | N | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103TC0700X | 23061 | TX | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 032747002 | 05 | TX | MEDICAID |