Basic Information
| Provider Information | |||||||||
| NPI: | 1790026847 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | KAITLIN | ||||||||
| MiddleName: | GAGE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3636 W IMPERIAL HWY | ||||||||
| Address2: | #112 | ||||||||
| City: | INGLEWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 903032751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102732018 | ||||||||
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| Practice Location | |||||||||
| Address1: | 18646 OXNARD ST | ||||||||
| Address2: | |||||||||
| City: | TARZANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913561411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189961051 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2013 | ||||||||
| LastUpdateDate: | 03/13/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.