Provider Demographics
NPI:1033634415
Name:LONG, EVAN CHRISTOPHER
Entity Type:Individual
Prefix:MR
First Name:EVAN
Middle Name:CHRISTOPHER
Last Name:LONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1265 N 170 W
Mailing Address - Street 2:
Mailing Address - City:ANGOLA
Mailing Address - State:IN
Mailing Address - Zip Code:46703-9416
Mailing Address - Country:US
Mailing Address - Phone:765-543-1367
Mailing Address - Fax:
Practice Address - Street 1:5755 N STATE ROAD 9
Practice Address - Street 2:
Practice Address - City:HOWE
Practice Address - State:IN
Practice Address - Zip Code:46746-9228
Practice Address - Country:US
Practice Address - Phone:765-543-1367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-07
Last Update Date:2017-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker