Provider Demographics
NPI:1194231019
Name:HARRIS, EVAN (LCSW, LISW)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:HARRIS
Suffix:
Gender:M
Credentials:LCSW, LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 51
Mailing Address - Street 2:
Mailing Address - City:PREEMPTION
Mailing Address - State:IL
Mailing Address - Zip Code:61276-0051
Mailing Address - Country:US
Mailing Address - Phone:309-236-9553
Mailing Address - Fax:
Practice Address - Street 1:100 19TH ST STE 102
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-8022
Practice Address - Country:US
Practice Address - Phone:309-236-9553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0084101041C0700X
IL149.0196331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical