Provider Demographics
NPI:1295217537
Name:LICHTENAUER, EVAN (DC)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:
Last Name:LICHTENAUER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9649 FAIRFAX BLVD
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-2321
Mailing Address - Country:US
Mailing Address - Phone:571-406-4102
Mailing Address - Fax:
Practice Address - Street 1:9649 FAIRFAX BLVD
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-2321
Practice Address - Country:US
Practice Address - Phone:571-406-4102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104-557487111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor