Provider Demographics
NPI:1164898664
Name:SCALL, EVAN OCONNELL
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:OCONNELL
Last Name:SCALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 SADDLE CLUB RD
Mailing Address - Street 2:
Mailing Address - City:EDGARTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02539-6547
Mailing Address - Country:US
Mailing Address - Phone:401-339-6501
Mailing Address - Fax:
Practice Address - Street 1:111 EDGARTOWN RD
Practice Address - Street 2:
Practice Address - City:OAK BLUFFS
Practice Address - State:MA
Practice Address - Zip Code:02557
Practice Address - Country:US
Practice Address - Phone:401-339-6501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-19
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program