Provider Demographics
NPI:1033273560
Name:EVANS, J. KELLIE YOUNG (LCSW,CSTOP)
Entity Type:Individual
Prefix:
First Name:J. KELLIE
Middle Name:YOUNG
Last Name:EVANS
Suffix:
Gender:F
Credentials:LCSW,CSTOP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 AIRLINE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-3912
Mailing Address - Country:US
Mailing Address - Phone:757-397-2121
Mailing Address - Fax:757-399-3316
Practice Address - Street 1:1805 AIRLINE BLVD
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23707-3912
Practice Address - Country:US
Practice Address - Phone:757-397-2121
Practice Address - Fax:757-399-3316
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical