Provider Demographics
NPI:1164420873
Name:EVANS, CAROL SUZANNE (PHD)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:SUZANNE
Last Name:EVANS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:CAROL
Other - Middle Name:SUZANNE
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:37 S CAYUGA RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-6705
Mailing Address - Country:US
Mailing Address - Phone:716-626-7492
Mailing Address - Fax:716-626-4496
Practice Address - Street 1:37 S CAYUGA RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-6705
Practice Address - Country:US
Practice Address - Phone:716-626-7492
Practice Address - Fax:716-626-4496
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013515103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYIA0411Medicare ID - Type Unspecified