Provider Demographics
NPI:1114798121
Name:EVANS, VIRGINIA SUE (MS)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:SUE
Last Name:EVANS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 N THOMPSON ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-4118
Mailing Address - Country:US
Mailing Address - Phone:417-841-7797
Mailing Address - Fax:
Practice Address - Street 1:2112 GREEN MEADOWS AVE
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-7877
Practice Address - Country:US
Practice Address - Phone:417-841-7797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR103TS0200X103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool