Provider Demographics
NPI:1083395362
Name:EVANS, ELLIOTT MARGARET (SWLC)
Entity Type:Individual
Prefix:
First Name:ELLIOTT
Middle Name:MARGARET
Last Name:EVANS
Suffix:
Gender:M
Credentials:SWLC
Other - Prefix:
Other - First Name:MARGARET
Other - Middle Name:HUNT
Other - Last Name:DEBONA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SWLC
Mailing Address - Street 1:1400 BURNS ST UNIT 1
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-2005
Mailing Address - Country:US
Mailing Address - Phone:828-215-0748
Mailing Address - Fax:
Practice Address - Street 1:3819 STEPHENS AVE STE 300
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-8522
Practice Address - Country:US
Practice Address - Phone:406-215-2225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-28
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-SWLC-LIC-634741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty