Provider Demographics
NPI:1538833058
Name:EVARISTE, GERALD (LCMHCA)
Entity type:Individual
Prefix:MR
First Name:GERALD
Middle Name:
Last Name:EVARISTE
Suffix:
Gender:M
Credentials:LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 W TRADE ST APT 455
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202-3376
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1935 J N PEASE PL STE 202
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-4542
Practice Address - Country:US
Practice Address - Phone:704-334-3170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-07
Last Update Date:2021-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA16758101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health