Provider Demographics
NPI:1578386942
Name:EVANS, DOMONIQUE (MS, LPC)
Entity type:Individual
Prefix:
First Name:DOMONIQUE
Middle Name:
Last Name:EVANS
Suffix:
Gender:
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 MONUMENT RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-1689
Mailing Address - Country:US
Mailing Address - Phone:877-927-0775
Mailing Address - Fax:
Practice Address - Street 1:4200 MONUMENT RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-1689
Practice Address - Country:US
Practice Address - Phone:877-927-0775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-05
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC17769101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health