Provider Demographics
NPI:1275877060
Name:EVANS, FARRELL M (CDS III)
Entity Type:Individual
Prefix:MISS
First Name:FARRELL
Middle Name:M
Last Name:EVANS
Suffix:
Gender:F
Credentials:CDS III
Other - Prefix:MISS
Other - First Name:FARRELL
Other - Middle Name:M
Other - Last Name:HISBADHORSE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CDS III
Mailing Address - Street 1:PO BOX 135
Mailing Address - Street 2:836 BRAVEWOLF
Mailing Address - City:BUSBY
Mailing Address - State:MT
Mailing Address - Zip Code:59016-0135
Mailing Address - Country:US
Mailing Address - Phone:406-477-4910
Mailing Address - Fax:406-477-8727
Practice Address - Street 1:100 EAGLE FEATHER STREET
Practice Address - Street 2:
Practice Address - City:LAME DEER
Practice Address - State:MT
Practice Address - Zip Code:59043
Practice Address - Country:US
Practice Address - Phone:406-477-4924
Practice Address - Fax:406-477-6727
Is Sole Proprietor?:No
Enumeration Date:2012-11-16
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANWIADSCB09/1711CCP101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)