Provider Demographics
NPI:1114151826
Name:EVANTER, ILENE R (LCSN, BCD)
Entity Type:Individual
Prefix:MS
First Name:ILENE
Middle Name:R
Last Name:EVANTER
Suffix:
Gender:F
Credentials:LCSN, BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6723 WHITTIER AVENUE
Mailing Address - Street 2:SUITE 405A
Mailing Address - City:MCLEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101
Mailing Address - Country:US
Mailing Address - Phone:571-201-5647
Mailing Address - Fax:
Practice Address - Street 1:6723 WHITTIER AVENUE
Practice Address - Street 2:SUITE 405A
Practice Address - City:MCLEAN
Practice Address - State:VA
Practice Address - Zip Code:22101
Practice Address - Country:US
Practice Address - Phone:571-201-5647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-08
Last Update Date:2009-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904000401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical