1366103202 NPI number — A'SA MARIAH FERNANDEZ EVANS LMSW

Table of content: A'SA MARIAH FERNANDEZ EVANS LMSW (NPI 1366103202)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366103202 NPI number — A'SA MARIAH FERNANDEZ EVANS LMSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FERNANDEZ EVANS
Provider First Name:
A'SA
Provider Middle Name:
MARIAH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
EVANS
Provider Other First Name:
A'SA
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1366103202
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/06/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
10/28/2024
NPI Reactivation Date:
11/06/2024

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1317 MONTERREY BLVD APT 134A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EULESS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76040-8181
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
682-386-6575
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9407 MIDWAY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75220-3850
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-353-8804
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/03/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  114148 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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