Provider Demographics
NPI:1104366723
Name:EVANS, WOODROW M
Entity Type:Individual
Prefix:MR
First Name:WOODROW
Middle Name:M
Last Name:EVANS
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 1:1850 LOGAN ST
Mailing Address - Street 2:1717 MARSHAL STREET
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-2316
Mailing Address - Country:US
Mailing Address - Phone:318-226-9944
Mailing Address - Fax:318-226-9946
Practice Address - Street 1:1717 MARSHALL ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4139
Practice Address - Country:US
Practice Address - Phone:318-226-9944
Practice Address - Fax:318-226-9946
Is Sole Proprietor?:No
Enumeration Date:2017-03-01
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA600720427Medicaid